Digital Forms - Image Orthodontics

WELCOME 
TO THE ORTHODONTIST. 

We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational.
We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.


Tell Us About Your Child

Tell Us About Your Child
Child's Name
This question is required
Child's Name
Phone Number
This question is required
Email
Please enter a valid email
Today's Date
/
/
Sex
Select...
Nickname
SS#
Child's Birthdate
/
/
Child's Age
School
/
/
Grade
Select...
Hobbies / Sports
Child's Home #
Child's Home Address
Street
City/Suburb
State
Zip/Post Code
Country

Who Is Accompanying Your Child Today?
Who Is Accompanying Your Child Today?
Name
Name
Relation
Do you have legal custody of this child?
Yes
No
Whom may we thank for referring you?
List brothers/sisters with age
General Dentist
Last Visit Date
Parent's Marital Status
Select...


Mother's Information
Mother's Information
Select...
Name
Birthdate
/
/
Email Address
Cell #
Home Phone
Employer
Work Phone
SS#
DL#

Father's Information
Select...
Name
Birthdate
/
/
Email Address
Cell #
Home Phone
Employer
Work Phone
SS#
DL#



Person Responsible For Account

Person Responsible For Account
Name
Name
Relation
Billing Address
Street
City/Suburb
State
Zip/Post Code
Country
Previous Address
Street
City/Suburb
State
Zip/Post Code
Country
Home Phone
DL#
Employer
Work Phone
Ext:
SS#

Who is responsible for making appointments?
Name
Name
Work Phone
Ext:
Home Phone

Neighbor or relatice not living with you.
Name
Name
Phone
Address
Street
City/Suburb
State
Zip/Post Code
Country


Primary Insurance
PRIMARY INSURANCE
Dental Coverage?
Yes
No
Dental Coverage?
Ortho Coverage?
Yes
No
Insurance Co. Name
Insurance Co. Address
Street
City/Suburb
State
Zip/Post Code
Country
Insurance Co. Phone
Group # (Plan, Local, or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate
/
/
Policy Owner's Employer

Secondary Insurance
SECONDARY INSURANCE
Dental Coverage?
Yes
No
Dental Coverage?
Ortho Coverage?
Yes
No
Insurance Co. Name
Insurance Co. Address
Street
City/Suburb
State
Zip/Post Code
Country
Insurance Co. Phone
Group # (Plan, Local, or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate
/
/
Policy Owner's Employer



What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes
No
Has your child been informed of any missing or extra permanent teeth?
Yes
No
Has your child ever had any pain/ tenderness in his/ her jaw joint (TMJ/TMD)?
Yes
No
Does your child brush his/her teeth daily?
Yes
No
Floss his/her teeth daily?
Yes
No
Child's Physician
Yes
No
Phone #
Date of Last Visit
/
/
Is your child currently under the care of a physician?
Yes
No
Has puberty begun?
Yes
No
Has menstruation begun? (Girls)
Yes
No
Has your child ever taken Phen-Fen?
(Also known as Redax or Pondimin)
Yes
No
(Also known as Redax or Pondimin)
If yes, when?
Please describe your child's current physical health
Select...
Please list all drugs that your child is currently taking
Please list all drugs/things that your child is allergic to:


Has your child ever had any of the following medical problems?
Has your child ever had any of the following medical problems?
Abdominal Bleeding
Yes
No
Abdominal Bleeding
ADD/ ADHD
Yes
No
Allergies to any Drugs
Yes
No
allergic to Latex/Metals
Yes
No
Allergic to Plastic
Yes
No
Any Hospital Stays
Yes
No
Any Operations
Yes
No
Artificial Bones/Joints/Valves
Yes
No
Asthma
Yes
No
Cancer
Yes
No
Congenitaal Heart Defect
Yes
No
Convulsions/Epilepsy
Yes
No
Diabetes
Yes
No
Handicaps/Disabilities
Yes
No
Hearing Impairment
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
HIV+/AIDS
Yes
No
Kidney Problems
Yes
No
Liver Problems
Yes
No
Lupus
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Sickle Cell disease/Traits
Yes
No
Tuberculosis (TB)
Yes
No
Please discuss any medical problems that your child has had

Does/ did your child have any of the following habits?
Does/ did your child have any of the following habits?
Clenching/Grinding Teeth
Yes
No
Clenching/Grinding Teeth
Lip Sucking/Biting
Yes
No
Mouth Breather
Yes
No
Nail Biting
Yes
No
Nursing Bottle
Yes
No
Speech Problems
Yes
No
Thumb/Finger Sucking
Yes
No
Tongue Thrust
Yes
No
Was your child breastfed?
Yes
No
I affirm the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need. if this office accepts insurance, I assign directly to Dr. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment to benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

My method of payment will be:
signature of parent or guardian 
Sign here
  
This question is required
Date
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/

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment feeds and may, at the discretion of this office, use the services of one or more credit reporting services.

Signature of parent guardian
Sign here
  
Date
/
/
Submit

The Parent or Guardian who accompanies the child is responsible for payment.

Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by  OSHA, the CDC and the ADA.