Orthodontic New Patient Form

Please allow approximately 10 minutes to fill out the new patient paperwork.

Patient Information
Step 1 of 8
Primary Contact Information
Step 2 of 8

Legal Guardian #1/Primary Contact

Legal Guardian #2/Secondary Contact (if applicable)

How Did You Hear About Us?
Step 3 of 8
Family Information (Optional)
Step 4 of 8

Name(s) of Children

Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth
Insurance Information (Primary & Secondary)
Step 5 of 8
Do you have insurance?

Primary Insurance

Secondary Insurance

Health Information
Step 6 of 8

Has the patient ever had any of the following? Please check all that apply:

Has the patient ever experienced any of the following? Please check all that apply:

Additional Questions:

Has the patient ever been evaluated for orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
Does the patient require antibiotics before dental treatment?
We use disclosing tablets and solutions to reveal harmful bacterial plaque on teeth. These disclosing products DO contain food dyes. Do you or your child have any food dye allergies?
Have adenoids or tonsils been removed?
Does the patient have any missing or extra permanent teeth?
Has the patient ever had any pain/tenderness in his/her jaw join (TMJ/TMD)?
Does the patient brush and floss his/her teeth daily?
Has the patient ever been prescribed Fosamax or any other bisphosphonate?
Are the patient's immunizations current?
Has the patient been admitted to the hospital or needed emergency care during the past two years?
Does the patient have any health problems that need further clarification? If yes, please explain:
Please list all drugs that the patient is currently taking
Please list all allergies the patient has
I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in medical status.
Permission To Take Orthodontic Records
Step 7 of 8

In order to best diagnose orthodontic treatment, there are three initial records we need to take. These records include intraoral photographs (taken with a digital camera), a panoramic x-ray that shows all the teeth in the mouth on one film, and a cephalometric x-ray that shows a side profile so the doctor can evaluate the patient's jaw position. These records will be taken at no charge during your consultation appointment.

For the patient's safety, we use low-radiation x-ray technology and will only take these radiographs if we do not have recent images on file. No photographs or x-rays will be used for any reason other than diagnostic purposes.

I have read and understand the above information and give Kids Care Dental permission to take photographs and x-rays.

HIPAA Notice of Privacy Practices
Step 8 of 8

Signature below is acknowledgement that you have read and understand the HIPAA Notice of Privacy Practices.

Pediatric Dentistry

Pediatric Dentistry

Providing a full range of dental services geared towards children. Start early, start right.

YES!
Preventive Care

Preventive Care

Critical in the overall oral and physical health of your child. Includes brushing and good oral hygiene techniques.

YES!
Orthodontics

Orthodontics

Several options to a healthier mouth and happier smile starts with early screenings.

YES!
First Visit

First Visit

Going to the dentist doesn't have to be an overwhelming experience. Our goal is provide a relaxing, stress-free environment.

YES!

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