Patient's Last Name First Name Middle
Patient's E-Mail Address : Preferred to be called Sex
Home Address
City State Zip
Patient Resides With   Mother Father Both Other
Home Phone Age Birth date
School Grade
Phone Number to Reach Someone During the Day
Please describe your child's orthodontic problem in your own words
Patients Interests
Your child's general dentist's name Referred By
Names and Ages of patient's brothers and sisters
Has anyone in the family had braces?   YES   NO with whom:
Date of last dental exam:
Parents Maritial Status Married Widowed Separated Single Divorced Remarried
Parents and Account Information Father
Name
Address   City, State, Zip ,	,
Phone
SSN
Employer's Name
Business Address   City, State, Zip  ,	,
Business Phone
Occupation
Mother
Name
Address   City, State, Zip  ,	,
Phone
SSN
Employer's Name
Business Address   City State, Zip	,
Business Phone
Occupation
Other Responsible Person
Name
Address   City, State, Zip  ,	,
Phone
Medical History
Physician's Name
Address   City, State, Zip  ,	,
Phone
NO YES Has your child experienced any health problems?      Explain : Any major change in your child's health recently?      Explain : Is your child currently under a physicians care?      Explain : Is your child currently taking medications?      Explain : Is your child allergic to any medications?      Explain : Has your child received a blood transfusion?      Explain : Have your child's tonsils or adenoids been removed      Explain : Has your child been in a risk group for AIDS?      Explain : Does your child require antibiotics before dental TX      Explain : Please check if your child has had any of the following conditions:   NO YES Heart Murmur Heart Surgery Developmental Disorder Asthma Hepatitis Diabetes Tuberculosis Growth Disorders Emotional Problems Frequent Headaches Bone Disorders Mouth Breather Is there any condition or problem that you think we should know about? Comments:
Dental History
Frequency of Dental Checkups Twice a year Once a year Only if a problem exists
NO YES Is there any unfinished care to be completed with your child's dentist?      Explain: Has your child had any face or dental injuries?      Explain : Is there a history of thumb or finger sucking?      Stopped? Does your child play any musical instrument?      What instrument? Has your child consulted an orthodontist previously?      With whom? Have teeth (either primary or permanent) been removed?   Has your child had any previous orthodontic treatment?      With whom? Is there any other information that may be helpful?
Insurance Information
Do you have orthodontic insurance :   YES         NO
A dental insurance policy is a contract between the insured and the insurance company.  Our professional services are rendered and charged directly to the patients account and the patient or person responsible for the account is responsible for payment of all fees incurred.  For your convenience, we will gladly assist you in submitting insurance claim forms from your insurance carrier pertaining to any charge for care in our office.  If you wish assistance, we ask that you provide us with claim forms to your insurance carrier on your first visit.  Otherwise we will assume you are submitting all claims to your insurance carrier.  We will accept assignment of benefits from your insurance company if possible.
Name of insured : (employee) SS# Date of Birth Name of insurance Company Group #     Name of insured : (employee) SS# Date of Birth Name of insurance company Group #

Lubbock Office 4601 50th St Suite 206 Lubbock, TX  79414 Phone: 806-792-8116	Lamesa Office 1009 North 7th Lamesa, TX  79331 Phone: 806-872-2865
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