Who Will Be Responsible for Bringing the Patient to Orthodontic Appointments?

DENTAL INSURANCE — PRIMARY

Primary Policy Holder’s Full Name

Relationship to Patient

Address and Phone (if not listed above)

DENTAL INSURANCE — SECONDARY

Secondary Policy Holder’s Full Name

Relationship to Patient

Address and Phone (if not listed above)

Patient’s Physician

Most Recent Physical Exam

Other physicians / health care providers being seen now:

Provider #1 — Name

Provider #1 — City, State

Provider #1 — Reason

Provider #2 — Name

Provider #2 — City, State

Provider #2 — Reason

Provider #3 — Name

Provider #3 — City, State

Provider #3 — Reason

Address, City, State

Other Dentist / Dental Specialist Name

Reason for Seeing Other Dentist / Dental Specialist

What concerns you about your child’s teeth?

What concerns your child about his/her/their teeth?

How does your child feel about orthodontic treatment?

Who suggested that your child might need orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment or consultations.

Does your child play a musical instrument?

Have any other family members been treated in this office? Please name them.

PATIENT HEALTH INFORMATION

Does the patient currently have (or ever had) a substance abuse problem?

Do you think that any of your child’s activities affect his/her/their face, teeth or jaws? How?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

Medication #1 — Taken For

Medication #2 — Taken For

Medication #3 — Taken For

Does your child chew or smoke tobacco?

Have you noticed any unusual changes in your child’s face or jaws?

Any other physical problems?

Your answers are for office records only and are confidential. For the following questions choose Yes, No, or DK/U.

Frequent oral habits (sucking finger, chewing pen, etc.)? — Age Stopped

Frequent habit of tongue thrust? — Age Stopped

Frequent habit of fingernail biting? — Age Stopped

Frequent habit of lip sucking? — Age Stopped

MEDICAL HISTORY — CONTINUED

ALLERGIES / REACTIONS

How Often Does Your Child Brush?

FAMILY MEDICAL HISTORY

Have the parents or siblings ever had any of the following health problems? If so, please explain.

Unusual Dental Problems

Other Family Medical Conditions?

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

Parent / Guardian Signature — Authorization(Required)

Date — Authorization(Required)

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

Child Medical History Form

PATIENT

PARENT / GUARDIAN

PARENT 1 / GUARDIAN

PARENT 2 / GUARDIAN

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE — PRIMARY

DENTAL INSURANCE — SECONDARY

PHYSICIAN

DENTIST

GENERAL INFORMATION

SIBLING #1

SIBLING #2

SIBLING #3

SIBLING #4

PATIENT HEALTH INFORMATION

DENTAL HISTORY

MEDICAL HISTORY

MEDICAL HISTORY — CONTINUED

ALLERGIES / REACTIONS

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Adult New Patient Registration Form

Our Services

Areas We Serve

Working Hours

Contact Us

Child Medical History Form

PATIENT

PARENT / GUARDIAN

PARENT 1 / GUARDIAN

PARENT 2 / GUARDIAN

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE — PRIMARY

DENTAL INSURANCE — SECONDARY

PHYSICIAN

DENTIST

GENERAL INFORMATION

SIBLING #1

SIBLING #2

SIBLING #3

SIBLING #4

PATIENT HEALTH INFORMATION

DENTAL HISTORY

MEDICAL HISTORY

MEDICAL HISTORY — CONTINUED

ALLERGIES / REACTIONS

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Adult New Patient Registration Form

EXCITING NEWS FROM ORIS DENTAL CLINICS!