Child Patient Form Step 1 of 7 14% We are really excited to meet you! How did you hear about us? (Select all that apply)* Google Facebook Instagram Referred by a dentist Referred by a family member Referred by a friend Saw your booth at an event Saw a printed advertisement Driving by Other If you were referred to our practice, whom may we thank for referring you? What are your chief concerns? (Select all that apply)* Crowding Spacing Overbite Underbite Cross bite Open bite Impacted teeth Missing teeth Extra teeth Jaw position Jaw pain/dysfunction Dentist recommended Other Is there anything specific that you would like to change about the appearance of your smile?*What type of treatment are you interested in?* Comprehensive Treatment - "I want everything fixed! I want my teeth straight, and my bite fixed if it needs it." Limited Treatment - "I just want my teeth straight; I don't care if my bite is off." Which METHOD of treatment are you most interested in?* Traditional metal braces Clear ceramic braces Clear aligner therapy "I'm open to whatever Dr. Hemphill recommends is best for my case." What aspects of treatment are most important to you? (Select all that apply)* Quality - "I want the best final result I can possibly get." Time/Speed - "I want my teeth straightened as fast as possible." Cost - "I'm looking for the most affordable option." Experience - "I want to enjoy the process and have a good experience with my treatment." Questions - "I have a lot of questions about my teeth, and I want to ask a specialist." We know your time is valuable. Sometimes our schedule allows for starting treatment the same day as your consultation. If time allows, would you be interested in staying after to save yourself a separate trip in the future?* Yes No Maybe Patient's Full Name*Patient's Preferred Name*Patient's Gender* Male Female Patient's Date of birth?* MM slash DD slash YYYY Patient's SSN#*Patient's Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number (if applicable)Email (if applicable) School*Grade*Hobbies/InterestsDentist's name (if able, please also include practice name, phone number, and email)*Approximate (or exact!) date of last dental cleaning and checkup* MM slash DD slash YYYY Has the child been evaluated by an orthodontist before?* Yes No Has the child had orthodontic treatment before?* Yes No Have we treated any family members? Please list.Custodial Parent/Guardian InformationRelationship to the patient?* Mother Father Stepmother Stepfather Guardian Other Full Name*Marital Status* Single Married Divorced Widowed Date of Birth?* MM slash DD slash YYYY SSN#*Cell Phone Number*Cell Phone Carrier* AT&T Verizon Sprint T-Mobile Metro PCS Cricket Wireless Other Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Employer*Job Title*How long at current job?*Add another guardian?* Yes No Relationship to the patient? Mother Father Stepmother Stepfather Guardian Other Full NameDate of Birth MM slash DD slash YYYY SSN#Cell Phone NumberCell Phone Carrier AT&T Verizon Sprint T-Mobile Metro PCS Cricket Wireless Other Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email EmployerJob TitleHow long at current job? Responsible Party InformationName of person financially responsible for account*Billing Address (if different from Home Address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number (if different from cell phone)Email Address Name of person responsible for scheduling appointments*Phone Number (if different from above)Email Address (if different from above) Do you have orthodontic insurance coverage?* Yes No Orthodontic Insurance InformationPolicy Owner's Name*Policy Owner's Date of Birth* MM slash DD slash YYYY Policy Owner's Relationship to PatientInsurance Company Name*Insurance Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Phone NumberGroup # (Plan, Local or Policy #)*ID# or SSN*Policy Owner's EmployerPolicy Owner's Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have secondary orthodontic insurance?* Yes No Policy Owner's Name*Policy Owner's Date of Birth* MM slash DD slash YYYY Policy Owner's Relationship to PatientInsurance Company Name*Insurance Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Phone NumberGroup # (Plan, Local or Policy #)*ID# or SSN*Policy Owner's EmployerPolicy Owner's Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Has your child ever had any of the following medical conditions?* Heart disease Congenital heart defect Blood disease Hemophilia Abnormal / prolonged bleeding Heart murmur Mitral valve prolapse Thyroid disease Bone disease Cancer Kidney / liver problems Endocrine problems Diabetes Problems with wound healing Asthma Convulsions / Epilepsy Emotional or nervous problems Hepatitis HIV + / AIDS Artificial bones / joints Artificial valves Mononucleosis Rheumatism or arthritis Rheumatic / Yellow / Scarlet fever Lupus Tuberculosis ADD / ADHD Handicaps / disabilities Hearing impairment None of the above Are you aware of any other disease, condition, or problem not listed above? (If yes, please describe.)*Has the patient ever had any hospital stays or operations? (If yes, please describe.)*Has the patient had tonsils and/or adenoids removed?* Yes No Does the patient smoke or use tobacco?* Yes No Is the patient under medical care?* Yes No Please describe the child's overall physical health:* Good Fair Poor Has the patient reached puberty?* Yes No Is the patient pregnant?* Yes No Is the patient currently taking any medications? (If yes, please list them here.)*Is the patient allergic to any drugs/latex/metals/plastics or other things? (If yes, please list allergies and type of reaction.)* Does the child BRUSH his/her teeth daily?* Yes No Does the child FLOSS his/her teeth daily?* Yes No Has the child had any of the following dental treatments?* Fillings Extractions Root canals Crowns Periodontal (gum) procedures None of the above Are you aware of any of the following dental problems?* Trauma/injury to teeth, mouth, jaws, or face Missing permanent teeth Extra permanent teeth Periodontal or "gum" problems Clicking/popping of the jaw Jaw discomfort or pain None of the above Has the child ever had any of the following habits or special problems?* Thumb / finger sucking Nail biting Lip biting Clenching / grinding of the teeth Tongue thrust Speech problems Mouth breathing None of the above Has a physician or dentist ever recommended that you take antibiotics before a dental appointment?* Yes No I certify that the information provided on this form is correct to the best of my knowledge. I understand that it is my responsibility to report any changes.* I agree This field is hidden when viewing the formParent NameThis field is hidden when viewing the formParent SignatureThis field is hidden when viewing the formDate SignedThis field is hidden when viewing the formStaff SignatureThis field is hidden when viewing the formDate SignedEmailThis field is for validation purposes and should be left unchanged.
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