(905) 281-8200265 Enfield Place, Suite 100B Mississauga25 King George Rd, Brantford, ON‎ 415 Fairview Dr, Brantford, ON

TROPICAL ORTHODONTICS

Braces | Orthodontic Specialists

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New Patient Form for Kids

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New Patient Form for Kids

If you have any questions about this form please email us at info@tropicalorthodontics.com
or call us at (905) 281-8200, we will be happy to help!

TELL US ABOUT YOUR CHILD

Nickname:*

Email address*

Child Name:*

Birthdate:

School:

Child’s Home #:

Age

Grade:

MALE

FEMALE

Hobbies / Sports:

Child'S Home Address:

City

Province

Postal Code

WHO IS ACCOMPANYING YOUR CHILD TODAY?

Name:

Do you have legal custody of this child?

Yes

No

Relation:

Whom may we thank for referring you?

General Dentist:

List brothers/sisters with age:

Last Visit Date:

Mother Information:

Stepmother

Guardian

Name

Email address*

Cell#:

Work #:

Birthdate:

Home #:

Employer:

Father Information:

Stepfather

Guardian

Name

Email address*

Cell#:

Work #:

Birthdate:

Home #:

Employer:

PERSON RESPONSIBLE FOR ACCOUNT

Name

Billing Address:

Work #:

Relation:

Home #:

Employer:

Who is responsible for making appointments?

Name:

Work #:

Home #:

Cell #:

PRIMARY ORTHODONTIC INSURANCE

Orthodontic Coverage:

Yes

No

Insurance Co. Phone #:

Policy Owner’s Name:

Policy Owner’s Birthdate:

Insurance Co. Name:

Group # (Plan, Local or Policy #):

Relationship to Patient:

Policy Owner’s Employer:

SECONDARY ORTHODONTIC INSURANCE

Orthodontic Coverage:

Yes

No

Insurance Co. Phone #:

Policy Owner’s Name:

Policy Owner’s Birthdate:

Insurance Co. Name:

Group # (Plan, Local or Policy #):

Relationship to Patient:

Policy Owner’s Employer:

What are the main concerns that you would like Orthodontic to accomplish

Has your child ever been evaluated or had Orthodontic treatment before?

Yes

No

Have adenoids or tonsils been removed?

Yes

No

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

Yes

No

Dose your child brush his / her teeth daily?

Yes

No

Floss his / her teeth daily?

Yes

No

Have there been any injuries to the face, mouth, teeth or chin?

Yes

No

Has your child been informed of any missing or extra permanent teeth?

Yes

No

Dose your child brush his / her teeth daily?

Yes

No

Floss his / her teeth daily?

Yes

No

Child’s Physician:

Phone #:

Is your child currently under the care of a Physician?

Yes

No

Has menstruation begun? (Girls)

Yes

No

Date of last Visit:

Has puberty begun?

Yes

No

Please describe your child’s current physical health:

Good

Fair

Poor

Please list all drugs that your child is currently taking:

Please list all drugs / things that your child is allergic to:

Latex

Yes

No

Metals / Nickel

Yes

No

Plastics

Yes

No

HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?

Abnormal Bleeding

Yes

No

ADD / ADHD

Yes

No

Allergies to any Drugs

Yes

No

Allergies to Latex / Metals

Yes

No

Allergies to Plastic

Yes

No

Any Hospital Stays

Yes

No

Any Operations

Yes

No

Artificial Bones / Joints / Valves

Yes

No

Asthma

Yes

No

Cancer

Yes

No

Congenital Heart Defect

Yes

No

Convulsions / epilepsy

Yes

No

Diabetes

Yes

No

Handicaps / Disabilities

Yes

No

Hearing Impairment

Yes

No

Heart Murmur

Yes

No

Hemophilia

Yes

No

Hepatitis

Yes

No

HIV+ /AIDS

Yes

No

Kidney / liver Problems

Yes

No

Rheumatic / scarlet Fever

Yes

No

Tuberculosis

Yes

No

Please discuss any medical problems that your child has had:

HAS YOUR CHILD EVER EXPERIENCED ANY OF THE FOLLOWING?

Clenching / Grinding Teeth

Yes

No

Speech Problems

Yes

No

Nail Biting

Yes

No

Nursing Bottle Habits

Yes

No

Mouth Breather

Yes

No

Tongue thrust

Yes

No

Lip Sucking / Bitting

Yes

No

Thumb / Finger Sucking

Yes

No

Neighbour or Relative not living with you

Name:

Phone:

Address:

I authorize the dental staff to preform the necessary dental services my child may need.

I understand that the information that i have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the service of one or more credit reporting service.

The Parent or Guardian who accompanies the child is responsible for payment. Our office is HIPPA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and ADA.

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mail: info@tropicalorthodontics.comTel: (905) 281-8200

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