Dr. Ferris

Child Registration Form

Patient Information

Gender
MaleFemale

Birth Date

Primary Phone Number

Primary Phone type
HomeCell

Parent/Guardian Information

Parent Marital Status
SingleMarriedDivorcedWidowedSignificant Other
Relationship

Birth Date

Primary Phone Number

Phone type
HomeCell
Secondary Phone Number

Phone type
HomeCellOther

Relationship

Birth Date

Primary Phone Number

Phone type
HomeCell
Secondary Phone Number

Phone type
HomeCellOther

Emergency Contact Information


Insurance Information

Primary Insurance Company













Secondary Insurance Company













Dental History


How did you hear about our Practice?
AdInternetFamily or FriendPhysicianOther

Has your child visited an orthodontist before?
YesNo

Has your child's tonsils or adenoids been removed?
YesNo
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
YesNo
Does your child have any missing or extra permanent teeth?
YesNo
Has your child ever had an injury to (select all that apply)?
TeethMouthChin
Does your child have speech problems?
YesNo
Does your child currently or has your child ever had any of the following habits?
Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

Medical History

Is your child currently being treated by a physician?
YesNo



Does your child have any allergies/sensitivities to medications or latex?
YesNo
Is your child currently taking any prescription or over-the-counter medications?
YesNo
Has puberty and/or menstruation begun?
YesNoN/A
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)?
YesNo
Has your child had any serious illnesses or operations?
YesNo
Has your child ever had a blood transfusion?
YesNo
Is your child pregnant?
YesNo
Nursing?
YesNo
Taking birth control pills?
YesNo
Check if your child has or have ever had any of the following:
Abnormal BleedingAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseBlood TransfusionCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart DefectCortisone TreatmentsCough, PersistentCoughing BloodDiabetesDifficulty BreathingDrug/Alcohol/AbuseEpilepsyEmphysemaFaintingFever Blisters/HerpesGlaucomaHeadachesHeart AttackHeart SurgeryHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHigh/Low Blood SugarHIV/AIDSHospitalized for Any ReasonJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShinglesShortness of BreathSickle Cell Disease/TraitsSinus ProblemsSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

Authorization



Date