Child Patient Form

Patient Information

* Patient First Name: (Required)

* Patient Last Name: (Required)

* Patient Prefers to be Called:

Gender: Male Female

Birth Date:

Age:

Is your child adopted? Yes No

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

Siblings (names and ages):

Parent / Guardian Information

Parent 1

First Name:

Last Name:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

E-mail:

Employer's Name:

Occupation:

Parent 2

First Name:

Last Name:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

E-mail:

Employer's Name:

Occupation:

Who is financially responsible? Parent 1 Parent 2 Both Other

Unencrypted email is not a secure form of communication. There is an inherent risk that content contained in such email/text messages may be misdirected, disclosed to or intercepted by, unauthorized third parties. Lexington Orthodontics will use the minimum necessary amount of protected health information in any communication. I agree that I am responsible for providing the dental practice any updates to my email address and/or mobile phone number.

Dental Insurance Information

Primary Dental Insurance

Primary Insurance Company:

Address:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's Date of Birth:

Employer:

Does this policy have orthodontic benefits? Yes No

Secondary Dental Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's Date of Birth:

Employer:

Does this policy have orthodontic benefits? Yes No

Dental History

General Dentist:

Date of Last Visit:

Who suggested that your child might need orthodontic treatment?

What are your main concerns about your child's teeth?

Has your child visited an orthodontist before? Yes No

If yes, when?: Reason:

Have we treated any other family members? Yes No

Name:

Does your child have any anxiety about dental appointments? Yes No

If yes, please explain:

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

If yes, please explain:

Does your child have any missing or extra permanent teeth? Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Select all that apply: Clenching/grinding of teeth Clicking/popping sounds in the jaw joint Inability to open/close mouth normally Jaw getting locked/stuck

Check if your child has or has ever had any of the following: Frequent canker sores or cold sores Enlarged Tonsils / Adenoids Thumb / Finger Sucking Difficulty breathing through nose Mouth breathing habit Snoring / Sleep Apnea

Medical History

Is your child currently being treated by a physician for any condition? Yes No

If yes, please explain:

Physician:

Date of Last Visit:

Phone:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has puberty and/or menstruation begun? Yes No NA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child had allergies or reactions to any of the following? Local anesthetics (novocaine, lidocaine, xylocaine) Latex (gloves, balloons) Metals/Nickel (jewelry, clothing snaps) Acrylic

Any other allergies (please list):

Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) or oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders or cancer? Yes No

Are there physical disabilities that need to be taken into consideration? (Examples: Difficulty with fine motor skills)

Are there learning disabilities that need to be taken into consideration? (Examples: Auditory processing difficulties, sensory integration dysfunction, speech and language difficulties)

Are there any emotional/psychiatric disorders that need to be taken into consideration? (Example: neurodevelopmental disorder, hyperactivity/attention-deficit disorder, autism spectrum disorder):

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims.

Submitted by:

Date: