Scroll to Main content, Navigation

Please Note:This site was designed with Cascading Stylesheets. You are seeing this note either because those Stylesheets didn't reach your machine or because you are using an outdated browser. You will still be able to view the textual content of this site. If you would like to upgrade your browser, please visit our Site Requirements page to view a list of browsers that support Cascading Stylesheets web standards.

Child Patient Personal Information
(all information provided is secure and confidential)

Consultation Date:
Name:
Address:
City:
State:
Zip Code:
Sex: Male Female
Date Of Birth: D M Y
Home Phone Number:
Cell Phone Number:
  
PARENT / GUARDIAN INFORMATION
Mother's Name (Dr/Mrs./Ms/Miss):
Address:
City:
State:
Zip Code:
Email:
Home Phone Number:
Work Number:
Mobile Number:
  Father's Name (Dr/Mr.):
  Address:
  City:
  State:
  Zip Code:
  Email:
  Home Phone Number:
  Work Number:
  Mobile Number:
Person(s) responsible for financial obligation:
Marital Status (check one)
Single Common law Married Separated Divorced Widowed
DENTAL HISTORY
Who is your family Dentist?
Have you seen a specialtist before?
Date of last dental   check-up:
If yes, when?
Have you ever required antibiotics or other medications prior to dental treatment? Yes No
Indicate any history of (check all that apply): Jaw joint problems Grinding and/or clenching of teeth
Thumb/finger sucking Injury to face or teeth Tongue position/or swallowing problems
Tonsils/Adenoids removed Speech/articulation problems Mouth breathing more than nose breathing
MEDICAL HISTORY
Family Physician: Date of last medical check-up:
Are you currently under medical care? Yes No If yes, explain:
Do you have any drug allergies?         Yes No If yes, explain:
Indicate any history of (check all that apply):
Epilepsy or seizures Hereditary problems Asthma Headaches
Hepatitis Heart murmur Heart problems H.I.V. Positive
Diabetes Anemia Prolonged bleeding  
Nickel/metal allergy Latex allergy Rheumatic fever Other:

Who may we thank for referring you?
Reason for today's visit:
I authorize DSI to do a clinical orthodontic examination and photographic documentation.

I consent to the discretionary and anonymous use of clinical photos and x-rays for DSI's educational/teaching purposes.
I consent to having reviewed DSI's privacy policy.
 
 
Signature _______________________________________________ Date _______________________________________________
INSURANCE INFORMATION
Insurance Plan 1 (please print) Insurance Plan 2 (please print)
Employee's Name:   Employee's Name:
Company Name:   Company Name:
Insurance Company:   Insurance Company:
Group/Policy Number:   Group/Policy Number:
Certificate/I.D.:   Certificate/I.D.:
Date of Birth (MM/DD/YY):   Date of Birth (MM/DD/YY):
Relationship to Patient:   Relationship to Patient: