Child New Patient Form

lexbraces.com - Child Registration Form

Patient Information

Gender:
Is your child adopted?
Phone Type

Parent / Guardian Information

Parent 1

Marital Status
Relation to Child:
Phone Type:

Parent 2

Marital Status
Relation to Child:
Phone Type:
Who is financially responsible?

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.

Insurance Information

Primary Insurance

Does this policy have orthodontic benefits?

Secondary Insurance

Does this policy have orthodontic benefits?

Dental History

Has your child visited an orthodontist before?
Have we treated any other family members?
Does your child have any anxiety about dental appointments?
Has your child ever had an injury to (select all that apply):
Does your child have any missing or extra permanent teeth?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Select all that apply:
Check if your child has or has ever had any of the following:

Medical History

Is your child currently being treated by a physician for any condition?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Check if your child has or has ever had any of the following:
Has your child had allergies or reactions to any of the following?
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?

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.



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Lexington Orthodontics

  • Lexington Orthodontics - 24 Muzzey Street, Lexington, MA 02421 Phone: 781-862-2625 Fax: 781-862-9169

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