We would like lo weltome vou otd your rhild lo our ol{ire.Our oool ir lo moke everv thild's visit oleosont ond edutotionol.We striye lo leoch good oro'l tore fid will enoble your lhild lo hove o beoulilul smile thot losts o liletime.

Nicknome:-C'lILD PBEFERS TO€E CALLED

Age:- EMole IFemole

Grode:

Child's Home #, (_)

Nome:- Relotion:

Billing Address:

Hm # (_)Cell + (_1

wk # (_)_Exr:_lflho is responsible for making appointments?Nome:

wk # (-)- Ext:

Do you hove legol custody of fiis child? E Yes X No

Whom moy we Thonk for referring you?

List brothers / sisters with oge:

. nSingle nPortnered nDivorcedPorenf's Moritol Stotus: tr Moiried n Seporoted n Widowed

lnsuronce Co. Phone #:

Group # (Plon, Locol, or

Poiicy Cwner's Nome:

Relotionship to Poiient:

?olicy *wn*r's Birthdote: / / lD #:

loi iey- Cwner's Em ployer:

9econderry

Orthodontic Coveroge?

Insuronce Co. Nome:

lnsuronce Co. Phone #: (-)Group # {P[on, Locol, or Policy #]:

Poiicy Cwn*r'* Name:

Relotionship to Potient:

P*licy Owr:ef* Birthdote:

F*iiey *wner's Employer:

E f,&e*E*+r's Eenf*rncu*5a*q: E Srep Morher tr Gro.dion

Hm #:(_)

E Flilrer's lnlormctiolrrNome:

ISt p roth.r Icuordion

Hos your child ever token Phen-Fen?(Also known os Redux or Pondimin) lf yes, when?

Hos your child ever been evoluoted or hod orthodontic

treotment before?

Hove there been ony inluries to the

foce, mouth, teeth or chin?

List ony musicol instruments ployed:

Hove odenoids or tonsils been removed? E Yes I No

Hos your child been informed of ony

missing or exlro permonent teeth?

l{os your child ever hod ony poin / tendernegs in his / het

iow ioint (IM, / IMDI?

Does your child brush his / her teeth doily? I Yes I No

Floss his / her teeth doily?

Child's Physicion:

Phone #: (-) Dote of Lost Visit:

ls your child currently under the core of o physicion?

IYes trNoEYes trNoEYes trNo

Pleose describe your child's current physicol heolth:IGood E Fqir I

Pleqse list oll drugs thot your child is currently roking:

PleEse list oll drugs / things ihot your child is ollergic to:

EYes trNo

EYes trNo

Hos puberty begun?

Hos menstruotion begun? (Girls)

Pleqse discuss ony medicol problems thot your child hos hod:

Y N Abnormol Bleeding

Y N ADD/ROHOY N Allergies to ony DrugsY N Allergic lo Lotex / Metols

Y N Allergic to Plostic

Y N Any Hospitol Stoyst' N Any OperotionsY N Artificiol Bones / Joints /

Volves

Y N Asthmo

Y N ConcerY N Congenitol Heort Defect

Y N Convulsions/EpilepsyY N Diobetesi N Hondicops/DisobilitiesY N Heoring lmpoirmentY N Heort Murmur\ N HemophilioY N Hepotitis

r N HIV+/AIDS',' N Kidney / Liver Problems!i N Lupus

Y N Rheumotic / Scorlet Fever

Y N Tuberculosis (TB)

i N Clenching / Grinding Teeth v N Nursing Bottle Hobits

';' N Lip Sucking / Biting Y N Speech Problems

Y N Mouth Breother 'l N Thumb / Finger Sucking

r N Noil Biting Y N Tongue Thrust

Neighbor or Relqtive nol living with you.

Nome

-Phone

(-)Address

I outhorize the dentol stoff to perform the necessory dentolservices my child moy need.correct io the best of my knowledge, thot it will be held in the

striciest of confidence ond it is my responsibility to inform this

office of ony chonges in my childt medirol stotus.

Signoture of porent or guordion

This office reseryes the right ro verify the credit stotus of potentiolpolients ond/or porenis of potients prior lo extending credit forlreolmeni fees ond moyr ot the discretion of lhis office, use lheservices of one or more credit reporling services.

Signoture of porent or guordion Dote

lf this office occepls insuronce, I undersiond thot I om responsiblefor poyment of services rendered ond olso responsible for poyrngony co-poyment ond deductibles lhot my insuronce does not cover.I hereby outhorize poyment of the group insuronce benefits directlyto this office. I oulhorize the use of this signoture on oll myinsuronre submissions, whether monuol or electronic.

Signoture of porent or guordion

! verbolly reviewed the medicql ,1 darrtol informotion obove wiih ihe porent / guordion ond potient nomed herein,

Doclor'g Gommenlss lnitiols:

BRACE YouRsEl"f FoRM #oRTHo-2c www.informsonline.(om o zOr i hfOi*S' ' r-8,aia-222.4gg4