Child New Patient Form

Child Registration Form - Ortho
* required field

Patient Information


Primary Phone Number

Parent/Guardian Information


Parents' Marital Status



Phone Number
Secondary Phone Number

Secondary Phone Number

Emergency Contact

Insurance Information

How did you hear about our Practice?

Who first noticed the need for orthodontic care?
Has your child visited an orthodontist before?

Do you (and your child) consider it

Dental History

Does your child or did your child have any of the following?
Are you or your child concerned with or have reservations about


Medical History

Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Currently under psychological guidance?
Check if your child has or have ever had any of the following:


I understand that the information that I have given today is correct to the best of my knowledge. I also 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 medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I understand that it is the policy of this office to bill and receive full payment from our patients.

Security Measure