Child Patient Form

Child Registration Form - Ortho

Patient Information





Parent / Guardian Information


Who will be responsible for this account?
Phone:

Dental History

How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?
Have we treated any other family members?
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 currently or has your child ever had any of the following (check all that apply)?










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?
Has your child reached puberty?
Has your child had any serious illnesses or operations? If yes, describe:
Check if your child has or has ever had any of the following:

Authorization

To the best of my knowledge, all of the answers are correct. If deemed advisable, I grant permission for my physician to be contacted for information and advice. If I have any change in health/medications that are not mentioned above, I will inform the doctor at my next visit.


Privacy Information

We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly.

I agree that Dr. J. Peterson and/or members or her staff have permission to release information concerning my dental/orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress.




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