New Custom Form-Child

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We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us!


Custom Child Registration Form

1. Tell Us About Your Child


2. Who Is Accompanying Your Child Today?

Do you have legal custody of this child?
Marital Status

3a. Mother's Information

Relation to Child:

3b. Father's Information

Relation to Child:

4. Person Responsible For Account

4a. Who Is Responsible For Making Appointments?

4b. Neighbor Or Relative Not Living With You.

5a. Primary Insurance

Dental Coverage:
Ortho Coverage:

5b. Secondary Insurance

Dental Coverage:
Ortho Coverage:

6. Main Conserns

Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in his / her jaw joint (TMJ/TMD)?
Does your child brush his / her teeth daily?
Floss his / her teeth daily?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun?
Has your child ever taken Phen-Fen?
Please describe your child's current physical health:

7.Has Your Child Ever Had Any Of The Following Medical Problems?

(check all that apply):

8.Does / Did Your Child Have Any Of The Following Habits?

(check all that apply):

9. Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

The Parent or Guardian who accompanies the child is responsible for payment.

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

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