Child Patient Form | North Shore Orthodontics

Child Patient Form

Tell us about your child

First
Last
Middle
MM slash DD slash YYYY
Gender(Required)
Siblings:

Who is with the child today

Do you have the custody of this child?
Parent Marital Status

Mother Information

Father Information

Responsible Party Info

Who is responsible for making appts.

Primary Dental Insurance

MM slash DD slash YYYY
Orthodontic Coverage

Secondary Dental Insurance

MM slash DD slash YYYY
Orthodontic Coverage

Why did you bring the child to the Orthodontist today?

Has the child ever had a serious/difficult problem associated with dental work?
Is the child's water fluoridated?
Is the child taking fluoridated supplements?
Has the child ever had any pain or tenderness in the jaw or joint (TMJ/TMD)?
Does the child brush teeth daily?
Floss their teeth daily?
Is the child currently under the care of a physician?
Please describe the child's health

Has the child ever had any of the following medical problems?

Child had any problem
Does the child have any of the following habits?

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

Consent(Required)

The Parent/guardian who accompanies the child is responsible for the payment at time of service unless prior arrangements have been approved.