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

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: