Child Registration Form "*" indicates required fields Step 1 of 7 - Patient Information 14% Patient InformationAll fields marked with an asterisk (*) are REQUIRED fields.Patient's Name*Gender Male Female Social Security Number*Date of Birth*Age*Home Address*City*State*Zipcode*Primary Phone Number*Primary Phone Type* Home Cell Email Address* School*Grade*List any sports or extracurricular activitiesSiblings (names and ages) Parent/Guardian InformationParent Marital Status Single Married Divorced Widowed Significant Other Parent RoleMotherFatherParent's NameSocial Security NumberDate of Birth (mm/dd/yyyy)Driver's License NumberAddress (if different from child's)CityStateZipcodePrimary Phone NumberPrimary Phone Type Home Cell Secondary Phone NumberSecondary Phone Type Home Cell Other EmployerOccupation Emergency Contact InformationEmergency Contact NamePhone NumberRelation to ChildAddressCityStateZipcodePerson(s) OK to release appointment or medically related information to concerning childRelation Insurance InformationPrimary InsuranceDo you have insurance?* Yes No Primary Insurance Company*Phone Number*Group Number*Policy Number*Member ID Number*Policy Holder's Name*Relation*Policy Holder's Social Security Number*Policy Holder's Birth Date (mm/dd/yyyy)*Employer*Work Phone Number*Co-pay (if known)*Deductible (if known)*Secondary InsuranceDo you have secondary insurance?* Yes No Secondary Insurance Company*Phone Number*Group Number*Policy Number*Member ID Number*Policy Holder's Name*Relation*Policy Holder's Social Security Number*Policy Holder Birth Date (mm/dd/yyyy)*Employer*Work Phone Number*Co-pay (if known)*Deductible (if known)* Dental HistoryGeneral Dentist NameLast Visit (mm/dd/yyyy)How did you hear about our Practice? Ad Internet Family or Friend Physician Other Name of person referring (if applicable)What are the main concerns you would like orthodontics to accomplish?Has your child visited an orthodontist before? Yes No WhenReasonHas your child's tonsils or adenoids been removed? Yes No Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No Does your child have any missing or extra permanent teeth? Yes No Has your child ever had an injury to (select all that apply)? Teeth Mouth Chin Does your child have speech problems? Yes No If yes, please explain:Does your child currently or has your child ever had any of the following habits? Clenching/Grinding Teeth Chewing/Eating Problems Lip Sucking/Biting Mouth Breathing Nail biting Thumb/ Finger Sucking Medical HistoryIs your child currently being treated by a physician? Yes No ReasonPhysicianDeductible (if known)Phone NumberDoes your child have any allergies/sensitivities to medications or latex? Yes No If yes, please list allergies:Is your child currently taking any prescription or over-the-counter medications? Yes No If yes, please list (with dosages):Has puberty and/or menstruation begun? Yes No Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No Has your child had any serious illnesses or operations? Yes No If yes, please describe:Has your child ever had a blood transfusion? Yes No If yes, give approximate dates:Is your child pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Check if your child has or have ever had any of the following: Abnormal Bleeding Anemia Arthritis / Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Blood Transfusion Cancer Chemical Dependency Chemotherapy Circulatory Problems Congenital Heart Defect Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Difficulty Breathing Drug / Alcohol Abuse Epilepsy Emphysema Fainting Fever Blisters / Herpes Glaucoma Headaches Heart Attack Heart Murmur Heart Problems Heart Surgery Hemophilia Hepatitis High Blood Pressure High / Low Blood Sugar HIV / AIDS Hospitalized for Any Reason Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Psychiatric Problems Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shingles Shortness of Breath Sickle Cell Disease / Traits Sinus Problems Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease AuthorizationI 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 reponsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my 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.Authorization Agreement* I have read and agree to the above Patient Signature and/or Responsible Party*Today's Date (mm/dd/yyyy)*PhoneThis field is for validation purposes and should be left unchanged.
