Child New Patient Information

Child Registration Form - Ortho
* required field

Patient Information



Gender*











Primary Phone Number*
















Parent/Guardian Information

Parent Marital Status*
Relationship















Phone Number*
Secondary Phone Number





Relationship







Phone
Secondary Phone Number



Insurance Information


















Dental History






How did you hear about our Practice?*

**
Does your child currently or has your child ever had any of the following?

Medical History

Does your child have any allergies/sensitivities to latex?*
*Has Your Child Had Any Rapid Growth?*
Has puberty and/or menstruation begun?*
Is Your Child Pregnant?
Has your child had any serious illnesses or operations? If yes, describe:
Check if your child has or have ever had any of the following:

Sleep / Airway Issues

Does Your Child Have Any Of The Following Sleep or Airway Issues?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.






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