Child Form

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Parent 1

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Parent 2

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Dental Insurance Information

Primary Dental Insurance

Primary Dental Insurance Company:

Dental Insurance Company Mailing Address:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Dental Insurance

Secondary Dental Insurance Company:

Dental Insurance Company Mailing Address:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

Has your child's dentist cleared them for orthodontic treatment? Yes No

What are the main concerns you would like orthodontics to correct?

Has your child visited an orthodontist before? Yes No

If yes, when?: Reason:

Have we treated any other family members? Yes No

Name:

Medical History

Is your child currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Is your child required to premedicate? Yes No

If yes, please list with the dosage:

Has puberty and/or menstruation begun? Yes No NA

If yes, when did it start:

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion? Yes No

If yes, give approximate dates:

If your child has a history of a medical condition not listed above, please list/describe the condition:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I consent to Wilborn Orthodontics to taking any necessary diagnostic records, consisting of x-rays, photographs, and dental impressions in order to diagnos and formulate an orthodontic treatment plan.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date: