Smile Every Day Dentistry & Orthodontics - Under 18 New Patient Form

1. Patient Information

Section 1 of 10

First Name

Middle Initial

Last Name

Prefers To Be Called

Birth Date

Sex

Male

Female

Social Security #

School Name

Grade

Home Address (Street)

Home Address (City)

Home Address (State)

Home Address (Zip)

Home Phone

( ) -

Cell Phone

( ) -

E-Mail Address(es)

2. Parent / Guardian Information

Section 2 of 10

Custodial Parent(s) Names (First/Last)

Patient Lives With (Check All That Apply)

Mother

Father

Stepmother

Stepfather

Grandparents

Other

Father's Full Name

Father's Title

Mr.

Dr.

Other

Father's Home Address (Street)

Father's City

Father's State

Father's Zip

Father's Home Phone

( ) -

Father's Cell Phone

( ) -

Father's E-Mail Address(es)

Father's Occupation

Father's Employer

Father's Work Phone

( ) -

Mother's Full Name

Mother's Title

Mrs.

Ms.

Dr.

Other

Mother's Home Address (Street)

Mother's City

Mother's State

Mother's Zip

Mother's Home Phone

( ) -

Mother's Cell Phone

( ) -

Mother's E-Mail Address(es)

Mother's Occupation

Mother's Employer

Mother's Work Phone

( ) -

3. Dentist Information

Section 3 of 10

Patient's Dentist

Last Seen

Reason (Routine or Other?)

Next Appointment

Dentist's Address (Street)

Dentist's City

Dentist's State

Other Dentist(s)/Dental Specialist(s) Now Being Seen

Other Dentist's City

Other Dentist's State

Reason for Seeing Other Dentist(s)/Dental Specialist(s)

4. General Information

Section 4 of 10

What concerns you about your child's teeth?

What concerns your child about his/her teeth?

How does your child feel about orthodontic treatment?

Does your child play a musical instrument?

Who suggested your child might need orthodontic treatment?

Why did you choose our office?

Has your child had any previous orthodontic treatment? Please Describe

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

5. Financial Responsibility

Section 5 of 10

Who is financially responsible for this account? (Full Name)

Social Security Number

Home Address (Street)

City

State

Zip

Home Phone

( ) -

Cell Phone

( ) -

E-Mail Address(es)

Occupation

Employer

Work Phone

( ) -

6. Dental Insurance

Section 6 of 10

Primary Policy Holder First Name

Middle Initial

Last Name

Birth Date

Social Security Number

Best Phone

( ) -

Relationship to Patient

Home Address (Street)

City

State

Zip

Employer

Employer Address (Street, City, State, Zip)

Insurance Company

Group Number

ID Number

Phone

Does Policy Have Orthodontic Benefits?

Yes

Don't Know

Secondary Policy Holder First Name

Middle Initial

Last Name

Birth Date

Social Security Number

Best Phone

( ) -

Relationship to Patient

Home Address (Street)

City

State

Zip

Employer

Employer Address (Street, City, State, Zip)

Insurance Company

Group Number

ID Number

Phone

Does Policy Have Orthodontic Benefits?

Yes

Don't Know

7. Medical / Dental History

Section 7 of 10

The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. The orthodontist will review the medical history and explain any questions that you do not understand. For the following questions, please mark “YES” “NO,” or “DON’T KNOW/UNDERSTAND (DK/U)”

MEDICAL HISTORY QUESTIONS: Now or in the past, have you had:

Yes No DK/U Is your child being treated for any medical condition at this time or has your child been treated for a medical condition within the past two years?

If yes, please explain

Yes No DK/U Has there been a change in your child’s health within the last two years?

If yes, please explain

Yes No DK/U Has your child ever had an adverse reaction to any medications, injections or anesthetics?

If yes, please explain

Yes No DK/U Has your child ever had his/her adenoids and/or tonsils removed?

Yes No DK/U Has your child ever had hepatitis, jaundice or a liver disorder?

Yes No DK/U Does your child have a bleeding problem or bleeding disorder?

Yes No DK/U Has your child ever been diagnosed with asthma?

Yes No DK/U Has your child ever had a replacement or repair of: a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes No DK/U Does your child have a prosthetic or artificial joint?

Yes No DK/U Does your child have any conditions or therapies that could effect his/her immune system (e.g. leukemia, AIDS, HIV, radiotherapy, chemotherapy)?

Yes No DK/U Has your child ever been hospitalized for any illness or operation?

If yes, please explain

Yes No DK/U Chest pain, angina

Yes No DK/U Rheumatic fever

Yes No DK/U Heart attack

Yes No DK/U Mitral valve prolapse

Yes No DK/U Heart murmur

Yes No DK/U Shortness of breath

Yes No DK/U Pacemaker

Yes No DK/U Diabetes

Yes No DK/U Tuberculosis

Yes No DK/U Stroke

Yes No DK/U Autism

Yes No DK/U Lung disease

Yes No DK/U Steroid therapy

Yes No DK/U Cancer

Yes No DK/U Stomach ulcers

Yes No DK/U Arthritis

Yes No DK/U Seizures/Epilepsy

Yes No DK/U Kidney disease

Yes No DK/U Thyroid disease

Yes No DK/U Drug/alcohol dependency

Yes No DK/U Nervous disorders

Yes No DK/U ADHD

Additional conditions not listed

DENTAL HISTORY QUESTIONS: Now or in the past, have you had:

Yes No DK/U Been nervous during dental treatment?

Yes No DK/U Mouth breather while sleeping or awake (or both)?

Yes No DK/U Had habits such as thumb/finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern?

Yes No DK/U Been informed of any missing or extra permanent teeth

Yes No DK/U Had injuries to your face, mouth or teeth?

Yes No DK/U Experienced any jaw joint noises, jaw joint pain or limited jaw movement?

Yes No DK/U Previously consulted an orthodontist?

Yes No DK/U Had any family member had orthodontic treatment?

ALLERGY QUESTIONS: Have you had allergies or reactions to any of the following?

Yes No DK/U Medications

Please List

Yes No DK/U Latex and/or rubber by-products

Please List

Yes No DK/U Other (e.g. foods, hayfever)

Please List

8. Patient Health Information

Section 8 of 10

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

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

Medication 1

Taken For

Medication 2

Taken For

Medication 3

Taken For

Has your child ever taken any medications to strengthen your bones? Please describe

Does your child takeantibiotic pre-medication before any dental procedures?

Yes

Does your child currently have (or has your child ever had) a substance abuse problem?

Does your child chew or smoke tobacco?

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

Any other physical problems?

How often does your child brush?

How often does your child floss?

9. Family Medical History

Section 9 of 10

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

Unusual Dental Problems

Jaw Size Imbalance

Other Family Medical Conditions

10. Release & Waiver Signature

Section 10 of 10

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this once of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the once. I understand that where appropriate, credit bureau reports may be obtained.

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 medical or dental health.

Name of Parent/Guardian filling out this form:

Date:

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PLEASE READ!!!

1. Patient Information

Section 1 of 10

2. Parent / Guardian Information

Section 2 of 10

3. Dentist Information

Section 3 of 10

4. General Information

Section 4 of 10

5. Financial Responsibility

Section 5 of 10

6. Dental Insurance

Section 6 of 10

7. Medical / Dental History

Section 7 of 10

MEDICAL HISTORY QUESTIONS: Now or in the past, have you had:

DENTAL HISTORY QUESTIONS: Now or in the past, have you had:

ALLERGY QUESTIONS: Have you had allergies or reactions to any of the following?

8. Patient Health Information

Section 8 of 10

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

9. Family Medical History

Section 9 of 10

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

10. Release & Waiver Signature

Section 10 of 10

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 medical or dental health.

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Please Verify That You Are Human!

Choose A Form Submission Option

Select whether you would like to submit the form --OR-- print it out and bring it with you to the office