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510-521-4822
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Child New Patient Information

Child New Patient Information

Patient Information

* Patient Name

Gender Male Female

Birth Date and Age

Home Address:

City, State & Zip

Primary Phone Number: Primary Phone Number School & Grade

List any sports or extracurricular activities:

Siblings (names and ages)

Parent/Guardian Information

Parent's Marital Status Single Married Divorced Widowed Significant Other

Relationship

Name

Social Security Number:

Birth Date:

Address (if different than child's):

City, State & Zip

Phone Phone Number Secondary Phone Number: Secondary Phone Number Employer & Occupation

Relationship

Name

Social Security Number:

Birth Date:

Address (if different than child's):

City, State & Zip

Phone Phone Number Secondary Phone Number: Secondary Phone Number Employer & Occupation

Insurance Information

Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holders Name

Relationship to Patient

Policy Holders Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holders Name

Relationship to Patient

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Work Phone Number

Dental History

General Dentist: Last Visit:

How did you hear about our Practice? Ad Internet Family or Friend Physician Other Dentist
Name of person referring (if applicable)

What are the main concerns you would like orthodontics to accomplish? Concerns

Has your child visited an orthodontist before? Yes No

Have your childs tonsils or adenoids been removed? Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Does your child you have any missing or extra permanent teeth? Yes No

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

Does your child have speech problems? Yes No
If so, explain:

Does your child currently or has your child ever had any of the following habits

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing

Nail biting
Thumb/Finger Sucking
Chewing/Eating Problems

Medical History

Is your child currently being treated by a physician? Yes No
Reason
Physician Name & Phone

Does your child have any allergies/sensitivities to medications or latex? Yes No
If yes, please list allergies:

Is your child currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Has puberty and/or menstruation begun? Yes No

Check if your child has or have ever had any of the following:

Arthritis Asthma Brain Injury Cancer Diabetes Epilepsy Heart Problems

Hepatitis Nervous Disorder Rheumatic Fever Tonsillitis Tuberculosis Headaches

Authorization

The information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

Patient Signature and/or Responsible Party

Date

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Alameda Orthodontics

Alameda Orthodontics - 2100 Otis Dr., Suite F Alameda, CA 94501 Phone: 510-521-4822

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