Child Registration Form - Ortho(correct)
* required field

Patient Information

Gender








Primary phone type





Parent/Guardian Information

Parent Marital Status
Who will be Financially Responsible? **Please see disclaimer at end of form.








Phone Type
Phone Type









Phone Type
Phone Type


Emergency Contact










Insurance Information






















Dental History


How did you hear about our Practice?

Has your child visited an orthodontist before?

Has your childs tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?






Medical History

Is your child currently being treated by a physician?


Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?


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.

In order for us to offer you the best possible payment plan options, this office verifies the credit status of potential patients and/or parents of potential patients prior to extending credit for treatment fees by using the services of one or more credit reporting services.



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