Digital Forms by Patientfy.com
 
 
Child Form
 
Your information is encrypted and processed through HITRUST CSF certified technology for HIPAA compliance.
 
Patient information
 

How'd you find us?*


 

Rate our new website*:


 

Child's first name*:


 

Child's last name*:


 

Nickname:


 

Date of birth*:


 

Age:


 

Gender:


 

School name:


 

School grade:


 

Address*:


 

City*:


 

State*:


 

Zip code*:


 

Tell us about your child*:

Name(s) of family members seen by Dr. Smith:


 
Parent / Guardian information
 
Mother / Guardian information
 

First name:


 

Last name:


 

Relationship to patient:


 

Marital status:


 

Address same as above?


 

Address:


 

City:


 

State:


 

Zip code:


 

Mobile number:


 

Mobile carrier:


 

Email:


 

Employer:


 

Work number & EXT:


 

Social security #:


 

Driver's license #:


 

Do you have legal custody of this child?


 
Father / Guardian information
  

First name:


 

Last name:


 

Relationship to patient:


 

Marital status:


 

Address same as above?


 

Address:


 

City:


 

State:


 

Zip code:


 

Mobile number:


 

Mobile carrier:


 

Email:


 

Employer:


 

Work number & EXT:


 

Social security #:


 

Driver's license #:


 

Do you have legal custody of this child?

Person Responsible for Account
 

First name*:


 

Last name*:


 

Relationship to patient*:


 

Billing address*:


 

City*:


 

State*:


 

Zip code*:


 

Mobile number*:


 

Email*:

Insurance information
   

Do you have orthodontic insurance?*


​​​​​​

Primary insurance

Feel free to upload your insurance card:

Front side:

Back side:


Name of dental insurance*:


Insurance phone #*:


Policy owner's name*:


Policy owner's birth date*:


Social security / ID #*:


Policy owner's employer*:


Relationship to patient*:


 

Secondary insurance

Feel free to upload your insurance card:

Front side:

Back side:


Name of dental insurance:


Insurance phone #:


Policy owner's name:


Policy owner's birth date:


Social security / ID #:


Policy owner's employer:


Relationship to patient:

Child's medical history
 

Has your child been diagnosed or treated for a medical condition?*


​​​​
Please indicate which medical conditions from the options below. Please complete this entire section.
 

ADHD*
 Yes   No

Aids/HIV positive*
 Yes   No

Autism*
 Yes   No

Anemia*
 Yes   No

Anxiety*
 Yes   No

Cancer*
 Yes   No
 

Diabetes*
 Yes   No

Difficulty Breathing*
 Yes   No

Drug/Alcohol Abuse*
 Yes   No

Emotional Problems*
 Yes   No

Epilepsy*
 Yes   No

Heart Condition*
 Yes   No
 

Heart Murmur*
 Yes   No

Hepatitis*
 Yes   No

Lung Disorders*
 Yes   No

Psychiatric Problems*
 Yes   No

Radiation Treatment*
 Yes   No

Sinus Problems*
 Yes   No
 

Speech/Hearing Problems*
 Yes   No

Tuberculosis*
 Yes   No

Vision Problems*
 Yes   No
 

Is the child in good health?*


 

If "No", please explain. If "Yes", type "In Good Health"*:


 

Child's physician’s name*:


 

Date of last visit*:


 

Is the child taking any medications (include over-the-counter)?*


 

List the medications the child is currently taking. Else, type "None"*:


 

Have the child's adenoid and/or tonsils been removed?*


 

If "Yes", when? Else, type "None"*


 

Does your child suffer from allergies?*


​​​​​​
Is your child allergic to the below? Please complete this entire section.
 

Anesthetics*
 Yes   No

Aspirin*
 Yes   No

Amoxicillin*
 Yes   No
 

Codeine*
 Yes   No

Cyclosporins*
 Yes   No

Erythromycin*
 Yes   No
 

Latex*
 Yes   No

Nickel*
 Yes   No

Penicillin*
 Yes   No
 

Sulfa Drugs*
 Yes   No

Tetracycline*
 Yes   No

Other*
 Yes   No
 

If you checked "Other" in the above question, please list any other medicines or materials the child is allergic to. Else, type "None"*:

Child's dental history
  

Child's last dental visit*:


 

Child's general dentist name*:


 

Child's general dentist phone*:


 
Please answer the following questions:
  
Have had complications following dental treatment?*
 Yes   No

Ever injured any teeth?*
 Yes   No

Ever injured jaw or face?*
 Yes   No

Currently have cavities/toothaches that need treatment?*
 Yes   No

Needs to be pre-medication before dental treatment?*
 Yes   No
 

Please explain the items you have answered "Yes". Else, type "None"*:

Acknowledgement

I have examined the above information and it is true and correct.
 

Signer first name*:


 

Signer last name*:


 

Signer email*:


 

Signer mobile*:


 
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Digital Forms by Patientfy.com