Dr. Ferris

Child Registration Form

  • 1

    Patient Information

  • 2

    Parent/Guardian Information

  • 3

    Emergency Contact Information

  • 4

    Insurance Information

  • 5

    Dental History

  • 6

    Medical History

  • 7

    Authorization

1/7

Patient Information

Gender
MaleFemale

Primary Phone type
HomeCell

0%

Parent Marital Status
SingleMarriedDivorcedWidowedSignificant Other

Phone type
HomeCell

Phone type
HomeCellOther

16%

33%


Primary Insurance Company

Secondary Insurance Company

50%

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 Teeth Lip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

66%

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?
YesNo

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

83%

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 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.


100%