New Patient Intake - Child

Patient Information

Name*

First Last

Date of Birth*

Gender*

Male
Female
Non-Binary
Prefer not to disclose

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

Would you like email reminders for appointments?

Yes
No

Parent/Guardian Information

Primary Parent/Guardian*

First Last

Phone (Cell)

Phone (Work)

Occupation

Employer

Add a second parent/guardian?

Yes
No

Secondary Parent/Guardian

First Last

Phone (Cell)

Phone (Work)

Occupation

Employer

Sibling's Names

Dental Information

Dentist's Name*

First Last

Referral Source

Do you have dental insurance covering orthodontics?*

Yes
No

Main Concern / Reason for Consultation

Please Note

Regular visits to your dentist must continue during orthodontic treatment.
Some appointments will infringe on school time or work.

Medical History

Have you or have you ever had any of the following?*

Rheumatic Fever
Diabetes
Chronic kidney problems
Lung problems
Epilepsy
Prolonged bleeding
Heart problems
Liver problems

When was your last dental checkup and cleaning?*

Do you have any allergies?*

Yes
No

What allergies do you have?*

Do you have any condition that could affect your immune system (e.g. AIDS, HIV, or Leukemia?)*

Yes
No

Describe the condition that could affect your immune system

Do you have any medical problems?*

Yes
No

Describe your medical problem

Do you take medication?*

Yes
No

What medication do you take?

Do you play any musical instruments?*

Yes
No

What musical instruments do you play?*

For females, have you reached menarche (monthly periods)?*

Yes
No

When did you reach menarche?

Do you have any of the following habits?*

Thumb/sooth sucking
Nail biting
Grinding teeth at night
Mouth breathing
Snoring

Has any member of the family had any orthodontic treatment?

Yes
No

Have you had any previous orthodontic consults or treatment?*

Yes
No

Permission & Signature

Consent*

I give permission to allow the clinic to report any findings to my dentist or any other dental professional as they deem necessary. I also give permission for any records made in the process of examination, treatment and retention to be used for purposes of research, education or publication in professional journals.*

Signature*