Child New Patient Form

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Child New Patient Form
* required field

Patient Information

Gender





Primary Phone Number





Parent/Guardian Information

Parent Marital Status
Relationship *





Phone Number

Secondary Phone Number
Untitled





Phone
Secondary Phone Number



Insurance Information












Dental History


How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?

Has your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?

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?
Has puberty and/or menstruation begun?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Check if your child has or have ever had any of the following:
Is your child premedicated before dental cleanings?

Authorization

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 further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.




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Click here for a fun page all about Dr. Fravel and to let him know some fun facts about YOU! 

Fill out this form and bring it in with you to your consultation appointment.

 Click here for the HIPAA forms. Please print, fill out, and bring in the forms for your first appointment.