Patient Information* RequiredPatient's Name*Preferred NameGender* Male FemaleDate of Birth* MM slash DD slash YYYY AgeSchoolAddress* Street Address Home PhoneDentist Full NameWho referred you to us?HobbiesBrothers/SistersParent/Guardian InformationMother's NameMother's Employer/OccupationMother's Work PhoneMother's Cell PhoneFor appointment reminders, who is your cell carrier? (Mother's)Mother's Email Father's NameFather's Employer/OccupationFather's Work PhoneFather's Cell PhoneFor appointment reminders, who is your cell carrier? (Father's)Father's Email Dental Insurance InformationDo you have dual orthodontic coverage? Yes No Don't KnowPolicy Owner's NameRelationship to PatientPolicy Owner's DOBMember ID or SSNPolicy Owner's EmployerInsurance CompanyGroup #Insurance Co. PhoneInsurance Co. Address Street Address Medical and Dental HistoryAre you currently under the care of a physician or anything about your health history that we should be aware of?* Yes NoIf yes, please explainPhysician's NamePhysician's PhoneCurrent medications and reason for taking:AllergiesHave you had your tonsils or adenoids removed? Yes NoHas patient had a sudden increase in height? Yes NoDoes patient visit the dentist regularly? Yes NoHas patient had any injuries to you head or mouth? Yes NoIf yes, please explain injuriesDoes patient have any jaw joint (TMD/TMJ) pain or discomfort? Yes NoDoes patient have any missing permanent teeth or extra teeth? Yes NoDoes patient have a speech problem or tongue thrust? Yes NoDo patient's gums bleed? Yes NoWhat are your chief concerns about your child's teeth?Would patient mind wearing braces or Invisalign? Yes NoHas patient been evaluated by another orthodontist? Yes NoWho is accompanying the patient to their appointment?Relationship to patient?SignatureSignature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.