Child Patient Form

* Required Fields Must be filled out accordingly in order to successfully submit the form.

First Name
Last Name
I prefer to be called
Mailing Address
Date of Birth
Home Phone
Home Email
School
Grade
Mothers First Name
Mothers Last Name
Mothers Employer
Mothers Business Phone
Mothers Business Email
Father's First Name
Father's Last Name
Father's Employer
Father's Business Phone
Father's Business Email
Who may we thank for referring you?
Family Dentists
Other family members seen in our practice
Does your child have any allergies?
If yes, please indicate what the allergy is
Does your child have any heart or circulatory problems?
Has our child ever undergone prolonged drug therapy for medical reasons?
List any serious medical problems
Are the tonsils and adenoids still present?
Name of the Financial Responsible Party & Relationship to child
Mailing address for Responsible Party if different than above
Child is in residence with
Will you require insurance forms?
Insurance Company Name
Policy Owner's Name
Relationship of Policy Owner to patient
Orthodontic Coverage
First Nation Coverage
If yes, please provide registry number
Are you aware of any oral habits such as Tongue Thrust
Are you aware of any oral habits such as Thumb or Finger Habit
Are you aware of any oral habits such as Lip Biting
Are you aware of any oral habits such as Mouth Breathing
Are you aware of any oral habits such as Speech Problems
Is the habit becoming less common?
Has your child ever been evaluated for or had orthodontic treatment before?
Has your child ever had any injuries to the face, mouth, teeth or chin?
Are you happy with the way your child's smile looks?
If not, what would you change?
Is your child concerned with his/her teeth or smile?
Has your child ever experienced pain in the jaw joint?
Has your child ever received a blow to his/her jaw?
If yes, please provide details
Has your child ever worn a biteplane?
Does your child grind or clench his/her teeth?
Has you child ever experienced noise in the joint when opening
Has you child ever experienced noise in the joint when closing
Has you child ever experienced locking open
Has you child ever experienced locking closed
Has you child ever experienced ringing in the ears
Has you child ever experienced headaches
Approximate date symptoms began
Is there anything special coming up in your child's life?
Does your child have any special interests or hobbies?
Does your child participate in sports? If yes, which sports?
Is there anything you think might be helpful for us to know?