New Patient Form - Child - Mischler Ortho

Patient Information

Patient Name *

Nickname or Preferred Name

Patient Date of Birth *

Patient's Age *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Please list other siblings and their ages:

Other family members treated at our office:

Who referred you to our office? *

Name of child's dentist:

Approximate date of last visit:

Parent/Guardian #1 Full Name *

First

Last

Relationship to Patient *

Do you have legal custody of this child? *

Yes
No

Cell Phone *

Email *

Parent/Guardian #1 Address (If different than patient)

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian #2 Full Name

First

Last

Relationship to Patient

Cell Phone

Email

Parent/Guardian #2 Address (If different than patient)

Address Line 1

Address Line 2

City

State

Zip Code

Responsible Party Information

Person Responsible for Account: *

Relationship to Child *

Date of Birth *

Dental Insurance Company

Subscriber Date of Birth

Medical History

For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Physician Name

First

Last

Date of Last Visit

Child's current Physical health is: *

Good
Fair
Poor

Have Tonsils or Adenoids been removed? *

Yes
No

Has puberty begun?

Yes
No

For Females: Has menstruation begun?

Yes
No

Is the child taking prescription/over-the-counter medications?

Yes
No

Please list any known allergies:

Has the child ever been evaluated for orthodontic treatment? *

Yes
No

Has the child ever experienced pain or discomfort in the jaw joint (TMJ/TMD)? *

Yes
No

Has the child ever had an injury to their: (Select all that apply)

Mouth
Teeth
Chin

Attestation

I understand that the information provided in this form is correct to the best of my knowledge. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. I understand that I am responsible for payment of services rendered and for any co-payment that my insurance does not cover, including the deductible. I understand that I am responsible for all costs of orthodontic treatment. I herby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.

Signature or Parent or Guardian *

Patient Information

Responsible Party Information

Medical History

Attestation

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