Child Registration Read Our Reviews Patient Information* RequiredPatient's Name*Preferred NameGender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY AgeSchoolAddress* Street Address Home PhoneDentist Full NameWho referred you to us?HobbiesBrothers/SistersParent/Guardian InformationMother's NameMother's Employer/OccupationMother's Work PhoneMother's Cell PhoneFor appointment reminders, who is your cell carrier? (Mother's)Mother's Email Father's NameFather's Employer/OccupationFather's Work PhoneFather's Cell PhoneFor appointment reminders, who is your cell carrier? (Father's)Father's Email Dental Insurance InformationDo you have dual orthodontic coverage?YesNoDon't KnowPolicy Owner's NameRelationship to PatientPolicy Owner's DOBMember ID or SSNPolicy Owner's EmployerInsurance CompanyGroup #Insurance Co. PhoneInsurance Co. Address Street Address Medical and Dental HistoryAre you currently under the care of a physician or anything about your health history that we should be aware of?*YesNoIf yes, please explainPhysician's NamePhysician's PhoneCurrent medications and reason for taking:AllergiesHave you had your tonsils or adenoids removed?YesNoHas patient had a sudden increase in height?YesNoDoes patient visit the dentist regularly?YesNoHas patient had any injuries to you head or mouth?YesNoIf yes, please explain injuriesDoes patient have any jaw joint (TMD/TMJ) pain or discomfort?YesNoDoes patient have any missing permanent teeth or extra teeth?YesNoDoes patient have a speech problem or tongue thrust?YesNoDo patient's gums bleed?YesNoWhat are your chief concerns about your child's teeth?Would patient mind wearing braces or Invisalign?YesNoHas patient been evaluated by another orthodontist?YesNoWho is accompanying the patient to their appointment?Relationship to patient?SignatureSignature*Date* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
