Child Form

    Patient/Child Information

    MaleFemale

    Home Address

    Financially Responsible Party Information (Who would be responsible for paying)

    MaleFemale

    Home Address

    Check if Address Same as Above Address

    Please check if there is a second responsible party

    yes

    MaleFemaleN/A

    Home Address

    Check if Address Same as Above Address

    [select phone2-type id:p2phone-type include_blank "Cell" "Home" "Work" readonly]

    Dental Insurance Information

    Yes I have insurance

    Do you have Dual coverage:

    yes

    Medical History

    Now or in the past, has the patient had:
    Attention Deficit DisorderAllergy to LatexArthritisBehavioural problemsBirth Defects or Hereditary ProblemsBone or Joint DisorderDiabetesEpilepsy or ConvulsionsFainting or DizzinessFrequent Headaches or MigrainesGagging or nausea problemsGrowth or Endocrine ConditionHearing DisorderHeart DisorderPsychiatric Treatment or Psychological Disorder

    YesNo

    YesNo

    Dental History

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.

    Patient/Legal Guardian Electronic Signature: