Please enable JavaScript in your browser to complete this form.Child's InformationPlease note some information is required. Child's Name *FirstMiddleLastNickname if preferredHas your child ever been EVALUATED for orthodontic treatment?YesNoMy child has gone through TREATMENT beforeAre they happy with the way their smile looks?YesNoThey're OK with their smileWhat are the MAIN orthodontic concerns you would like to fix for your child?Child's Birthdate *Child's Gender *FemaleMaleYour Information Your Name *FirstLastYour Relation to ChildMotherFatherOtherPlease describe your relation to the childStepmom, Grandfather, Guardian, etc...Your Preferred Email *Your Cell Phone *Your Home PhoneAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is the best method to contact you?CallTextEmailWhen is the best time to reach you?Please provide a specific time if neededHow did you hear about us? *Google / OnlineFamily / FriendSocial MediaDentistInsurance CompanyName of Person who Referred youMarital StatusSingleMarriedDivorcedWidowedName of SpouseSpouse's OccupationSpouse's CellName of Divorced ParentAddress of divorced parentAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone of divorced parent_________________________Employer InformationEmployer *If not employed, please leave BLANK__________________________DENTAL Insurance InformationPlease provide Dental Insurance under which your child is covered. This may be Spouse's Dental Insurance. Does your child have dental insurance coverage? *YesNoI think soName of Dental Insurance *I.e. Delta, Aetna, United Concordia... If you uploaded photos of your dental insurance card, please leave blank.Insurance Policy Holder's Name *Your name, if covered under your own insurance. Spouse or other's name, if covered under their insurance. Policy Holder's Date of Birth *Dental Insurance ID Number *This is required to determine insurance eligibility. Social Security Number of Policyholder *Please call our office if you prefer not to provide online.Dental Insurance Phone # *Insurance Company Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code__________________________Dental HistoryWho is your Child's Dentist (or last Dentist)? *If you do not have a current dentist, please respond: NoneWhen was their last dental visit?6 months or less6 months to 1 yearOver 1 yearHow would you describe your child's dental health?GoodFairPoorHave they ever had trauma to their Teeth or Jaws?YesNoPlease describe the injury to their teeth or jaws, including the date it happened:Have they Ever had a Serious/Difficult problem associated with anyPrevious Dental Work?YesNoPlease describe previous dental problemsHave they Ever experienced Pain or Discomfort in the Jaw Joint (TMJ?)YesNoPlease describe pain in TMJ?Do they have any speech problems?YesNoDo they generally breathe through their mouth?YesNo_________________________Medical HistoryThis section will determine if there are any medical concerns that may interfere with orthodontic treatmentIs your child allergic to Latex, Nickel, or any other products that may concern you? *YesNoPlease describe allergyex. Nickel, causes hives. Latex, causes rash.Has your child EVER been under the care of a physician for a medical condition or chronic illness?YesNoPlease describe the medical condition requiring a physician's care: I.e. Asthma, Lymes Disease, etc...Is your child taking prescribed medications?YesNoPlease List prescribed medications:I.e. Methylphenidate (Concerta) for ADHD.... or Fluticasone (Flovent) for asthma, etc...Has your child ever been hospitalized for a life threatening injury / disease?YesNoPlease describe reason for hospitalization:Has your child ever been diagnosed with:HepatitisHerpes / Fever BlistersHIV / AIDSRheumatic / Scarlet FeverTuberculosisAbnormal Bleeding / HemopheliaAnemiaArthritisAsthmaCancerCongenital Heart DefectDiabetesDifficulty BreathingEmphysemaEpilepsy / SeizuresFainting SpellsFrequent HeadachesHay FeverHeart MurmurHigh Blood PressureLow Blood PressureKidney ProblemsLiver DiseaseLupusMitral Valve ProlapsePsychiatric ProblemsSickle Cell Disease / TraitSinus ProblemsThyroid ProblemsUlcersAre there any Additional Concerns you have that were not addressed above?WebsiteSubmit
