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Child New Patient Information

Child Registration Form - Ortho

Patient Information


 




Parent / Guardian Information

Parents' Marital Status

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?
Have we treated any other family members?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Does your child 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 (check all that apply)?



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 your child had any serious illnesses or operations? If yes, describe:

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's 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.

I understand that where appropriate, credit bureau reports may be obtained.



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Hartsock Orthodontics

  • Hartsock Orthodontics - 161 College St., Suite 3, Pikeville, KY 41501 Phone: 606.432.3603

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