Child Registration Form

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We would like to welcome you to our office. In an effort to provide the best service, we ask you to fill out this form as completely as possible.

Thank you!

Child Registration Form - Dental 2
* required field

Child Registration Form

Patient Information


Sex


Primary phone number



RESPONSIBLE PARTY INFORMATION

Parent/Guardian Information






Primary phone number

Secondary Phone Number

Work phone number




Parent/Guardian Information





Primary Phone Number

Secondary Phone Number

Work phone number





DENTAL INSURANCE INFORMATION

Primary Dental Insurance







Secondary Dental Insurance








Medical History

Is your child currently under the care of a physician?





Does your child have any allergies to medications?

Has the patients tonsils and/or adenoids been removed?
What school does the patient attend?

Hobbies/Interests?

Does the patient have brothers or sisters? If so please include ages and names.

Please list any other immediate family members who have been treated by Champlain Orthodontics

DENTAL HISTORY

Has the patient ever been evaluated for orthodontic treatment?

Has the patient ever experienced jaw pain/discomfort (TMJ/TMD)?
Does the patient have any missing or extra permanent teeth? Unknown
Has the patient ever had an injury to (select all that apply):
Please explain injury:

Does the patient have speech problems?
Does/Has the patient ever had any of the following habits?









Emergency Contact




PURPOSE OF CONSENT

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences, and it is my responsibility to inform this office of any changes in the patients medical status. I understand, where appropriate, credit bureau reports may be obtained.




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