Patient Information-Child

Child Registration Form - Ortho
* required field

Patient Information












Parent/Guardian Information

Marital Status
Relationship to Patient









Are you the primary financial responsible party?
Are you primary person who will bring child to appointments?
Relationship to patient









Are you the primary financial responsible party?
Are you the primary person for bringing child to appointments?

Dental Insurance Information










Permission to Verify Insurance and Assign Benefits










Medical/Dental History

How did you hear about our office?
Has your child been seen by an orthodontist before?
Does your child have any missing or extra permanent teeth?
Does your child have any of the following habits?
Has your child ever had an injury to (select all that apply)

Does your child have any allergies/sensitivities to medications or latex?
Has your child had any serious illnesses or operations?
If yes, please explain
Has puberty and/or menstruation begun?
Please check if your child has or has had any of the following

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 the medical status. I hereby authorize the release of any information pertaining to medical/dental treatment necessary to process any insurance claims. I further authorize the application of 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.




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