Patient Form (Child)

  • Responsible Party Information

  • Dental Insurance Information

  • Emergency Information

  • Name/Signature
  • Medical History

  • If yes, please specify what medication
  • If yes, please specify what medication
  • If yes, please specify what illness
  • If yes, please specify
  • If yes, please specify
  • Dental History

  • How did they feel about the result?
  • Mom & Dad
  • Benefits

    Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. ____________________ to perform a complete orthodontic evaluation.