Child New Patient Registration Form Please fill out the form below or print, fill out and bring into our office on your first visit: Patient Name(Required)Sex(Required)Birth Date(Required) MM slash DD slash YYYY Preferred NameSchool(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Parent 1's Name(Required)Parent 2's Name(Required)Parent 1's Employer(Required)Parent 2's Employer(Required)Parent 1's Work/Cell Phone(Required)Parent 2's Work/Cell Phone(Required)Person responsible for making appts(Required)Parents’ Marital Status(Required)Parent 1’s Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2's Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person/People Responsible for Account(Required)Does the patient have orthodontic insurance?(Required) Yes No Company(Required)Policy Holder Name(Required)DOB(Required) MM slash DD slash YYYY Policy ID #(Required)Patient’s Regular Dentist(Required)Did they refer you here?(Required) Yes No Date of Last Dental Exam(Required) MM slash DD slash YYYY Patient’s Physician(Required)Whom may we thank for referring you to our office?(Required)Why are you are seeking orthodontic treatment?(Required)Has the patient been or are you currently treated for any medical/psychological issues? (please list)(Required)Is the patient taking any medications? (please list)(Required)Has the patient had any injuries or operations involving the head, neck, or teeth? Please explain(Required)Is the patient allergic to anything (please list)(Required)Does the patient have a sensitivity to latex gloves?(Required) Yes No Has the patient ever had pain/clicking/tenderness of the jaw joint (TMD/TMJ)(Required) Yes No Has the patient been informed of any missing or extra permanent teeth?(Required) Yes No Patient's Height(Required)Parent 1's Height(Required)Parent 2's Height(Required)Do you have a have a history of(Required) Clenching/grinding teeth Thumb/finger sucking Lip sucking/biting Tongue thrust None of the above It is important that the above information is correct and complete. It will be held in the strictest of confidence and used only for in-office treatment and paperwork. Your permission will be required to share given information with any other party.