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Treatment
Miscellaneous
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- Glossary
Contact Us

New Custom Form-Child

Dr. Jon Scott » Patient » Patient Forms » 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!

Hampton Office

2108 Hartford Rd.
Hampton, VA 23666
(757) 825-6280

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New Custom Form-Child

Patient Forms

New Custom Form-Child

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Custom Child Registration Form

1. Tell Us About Your Child

Today's Date:

Gender: Male Female

* Child's Name: (Required)

Nickname:

Social Security Number:

Child's Birth Date:

Child's Age:

School:

Grade:

Hobbies / Sports:

Child's Home Phone:

Child's Home Address:

City:

State:

Zip:

2. Who Is Accompanying Your Child Today?

Name:

Relation:

Do you have legal custody of this child? Yes No

Whom may we thank for referring you?

List brothers / sisters with age:

General Dentist:

Last Visit Date:

Marital Status Single Married Divorced Widowed Significant Other

3a. Mother's Information

Relation to Child: Mother Step-Mother Guardian

Name:

Birth Date:

Work Phone:

Home Home:

Employer:

How Long at Current Job:

Job Title:

Social Security Number:

Driver's License Number:

3b. Father's Information

Relation to Child: Father Step-Father Guardian

Name:

Birth Date:

Work Phone:

Home Phone:

Employer:

How Long at Current Job:

Job Title:

Social Security Number:

Driver's License Number:

4. Person Responsible For Account

Name:

Relation:

Billing Address:

City:

State:

Zip:

Previous Address:

City:

State:

Zip:

Home Phone:

Driver's License Number:

Employer:

Work Phone:

Social Security Number:

4a. Who Is Responsible For Making Appointments?

Name:

Home Phone:

Work Phone:

Social Security Number:

4b. Neighbor Or Relative Not Living With You.

Name:

Phone:

Neighbor's Address:

City:

State:

Zip:

5a. Primary Insurance

Dental Coverage: Yes No

Ortho Coverage: Yes No

Insurance Co. Name:

Insurance Co. Address:

City:

State:

Zip:

Insurance Co. Phone:

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relation to Patient:

Policy Owner's Date of Birth:

ID #:

Policy Owner's Employer:

5b. Secondary Insurance

Dental Coverage: Yes No

Ortho Coverage: Yes No

Insurance Co. Name:

Insurance Co. Address:

City:

State:

Zip:

Insurance Co. Phone:

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relation to Patient:

Policy Owner's Date of Birth:

ID #:

Policy Owner's Employer:

6. Main Conserns

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

Has your child ever been evaluated or had orthodontic treatment before? Yes No

Have there been any injuries to the face, mouth, teeth or chin? Yes No

List any musical instruments played:

Have adenoids or tonsils been removed? Yes No

Has your child been informed of any missing or extra permanent teeth? Yes No

Has your child ever had any pain/tenderness in his / her jaw joint (TMJ/TMD)? Yes No

Does your child brush his / her teeth daily? Yes No

Floss his / her teeth daily? Yes No

General Dentist:

Phone:

Last Visit:

Is your child currently under the care of a physician? Yes No

Has puberty begun? Yes No

Has menstruation begun? Yes No

Has your child ever taken Phen-Fen? Yes No

(Also known as Redux or Pondimin) If yes, when?

Please describe your child's current physical health: Good Fair Poor

Please list all drugs that your child is currently taking:

Please list all drugs/things that your child is allergic to:

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

(check all that apply): Abnormal Bleeding ADD / ADHD Allergies to any Drugs Allergic to Latex / Metals Allergic to Plastic Any Hospital Stays Any Operations Artificial Bones / Joints / Valves Asthma Cancer Congenital Heart Defect Convulsions / Epilepsy Diabetes Handicaps / Disabilities Hearing Impairment Heart Murmur Hemophilia Hepatitis HIV / AIDS Kidney Problems Liver Problems Lupus Rheumatic / Scarlet Fever Sickle Cell Disease / Traits Tuberculosis

Please discuss any medical problems that your child has had:

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

(check all that apply): Clenching / Grinding Teeth Lip Sucking / Biting Mouth Breather Nail Biting Nursing Bottle Speech Problems Thumb/Finger Sucking Tongue Thrust Was your child breast fed?

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.

My medthod of payment will be:

Signature of parent or guardian:

Date:

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.

Signature of parent or guardian:

Date:

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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New Custom Form-Child

Contact Us

Hampton Office

1. Tell Us About Your Child

2. Who Is Accompanying Your Child Today?

3a. Mother's Information

3b. Father's Information

4. Person Responsible For Account

4a. Who Is Responsible For Making Appointments?

4b. Neighbor Or Relative Not Living With You.

5a. Primary Insurance

5b. Secondary Insurance

6. Main Conserns

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

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

9. Authorization

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.