New Patient Form – Child

Patient Information
Name*
First Last
Gender
- Male
- Female
Social Security Number
Birth Date

MM/DD/YYYY
Age
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
- home
- cell
Can we leave you a message?
- Yes
- No
Email
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parent / Guardian Information
Marital Status
Name
First Last
Social Security Number
Birth Date
MM slash DD slash YYYY
Driving License Number
Address (if different than child's):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
- Home
- Cell
Secondary Phone Number
- Home
- Cell
Employer's Name
First Last
Occupation
Name
First Last
Social Security Number
Birth Date
MM slash DD slash YYYY
Driving License Number
Address (if different than child's):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
- Home
- Cell
Secondary Phone Number
- Home
- Cell
Employer's Name
First Last
Occupation
Emergency Contact Information
Emergency Contact Name (other than parent)
First Last
Phone Number
Relation to child
Address (if different than child's):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person(s) OK to release appointment or medically related information to concerning child
Relation(s) to child
Insurance Information
Primary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
First Last
Relationship
Policy Holder's Social Security Number
Policy Holder's Date of Birth
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Secondary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
First Last
Relationship
Policy Holder's Social Security Number
Policy Holder's Date of Birth
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Dental History
General Dentist
Last Visit

MM/DD/YYYY
How did you hear about us?*
- Ad
- Internet
- Family/Friend
- Physician
- Other
Name of person referring (if applicable)
First Last
What are the main concerns you would like Barlow Orthodontics to accomplish? Concerns
Have you visited an orthodontist before?
- Yes
- No
When
Reason
Have we treated any other family members?
- Yes
- No
Name
First Last
Have your tonsils or adenoids been removed?
- Yes
- No
Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
- Yes
- No
Do you have any missing or extra permanent teeth?
- Yes
- No
Have you ever had an injury to (select all that apply):
- Teeth
- Mouth
- Chin
Do you have speech problems?
- Yes
- No
If so, explain
Does your child currently or has your child ever had any of the following habits (check all that apply)?
- Clenching/Grinding Teeth
- Lip Sucking/Biting
- Mouth Breathing
- Nail Biting
- Thumb/Finger Sucking
- Chewing/Eating Problem
Medical History
Is your child currently being treated by a physician?
- Yes
- No
If yes, what for?
Is your child up to date with All Physician Recommended Vaccines?
- Yes
- No
If no, please explain:
Physician
Last Visit

MM/DD/YYYY
Phone
Does your child have any allergies/sensitivities to medications or latex?
- Yes
- No
If yes, please list
Is your child currently taking any prescription or over-the-counter medications?
- Yes
- No
Please list, with dosage
Has puberty and/or menstruation begun?
- Yes
- No
- NA
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
- Yes
- No
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
- Yes
- No
If yes, give approximate dates
Check if your child has or has ever had any of the following:
- Anemia
- Arthritis
- Artificial Heart Valves
- Artificial Joints
- Asthma
- Back Problems
- Blood Disease
- Cancer
- Chemical Dependency
- Circulatory Problems
- Cortisone Treatments
- Coughing Blood
- Diabetes
- Epilepsy
- Fainting
- Glaucoma
- Headaches
- Heart Murmur
- Heart Problems
- Hemophilia
- Hepatitis
- High Blood Pressure
- HIV/AIDS
- Jaw Pain
- Kidney Disease
- Liver Disease
- Mitral Valve Prolapse
- Pacemaker
- Radiation Treatment
- Respiratory Disease
- Rheumatic Fever
- Scarlet Fever
- Shortness of Breath
- Skin Rash
- Stroke
- Swelling of Feet or Ankles
- Thyroid Problems
- Tobacco Habit
- Tonsilitis
- Tuberculosis
- Ulcer
- Venereal Disease (STD)
Are there any other health hx issues Dr. Barlow should be aware of?
For Female Patients Only
Are you pregnant?
- Yes
- No
Are you nursing?
- Yes
- No
Are you taking birth control pills?
- Yes
- No
Terms of Agreement
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 medical status. I hereby authorize the release of any information pertaining to my 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.
Submitted by

By typing my name, I acknowledge I agree to the terms of agreement mentioned above.
Date
MM slash DD slash YYYY
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New Patient Form – Child

Patient Information

Parent / Guardian Information

Emergency Contact Information

Insurance Information

Dental History

Medical History

For Female Patients Only

Terms of Agreement

Please enter the verification codes listed below to continue with submitting your form.