Child New Patient Information

Child Registration Form - Ortho

Patient Information








Parent / Guardian Information

Parents' Marital Status











Emergency Contact Information

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Insurance Information



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Dental History

How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Is a family member currently in treatment?Has a family member received treatment in our office?
Has your child visited an orthodontist before?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
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 puberty and/or menstruation begun?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

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.



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ELD Orthodontics

  • Kendallville - 1919 Dowling St., Kendallville, IN 46755 Phone: 260.347.5575
  • Angola - 610 Wayne Plaza, Angola, IN 46703 Phone: 260.665.9534

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