Commerce Park Children's Dentistry & Orthodontics

home > insurance & billing > orthodontic registration form

Othodontic Registration Form

If you do not wish to submit this form online, you can download a printable form (requires Adobe Acrobat®).

Patient Information

Last Name
First Name
Middle Initial
Sex
Prefers to be addressed by
Date of Birth	/ /
Age (years)
Address
Apt. #
City
State
Zip
Home Telephone
Cell Phone#
Other family members treated at this office

Parental Information

Mother
Name
Date of Birth	/ /
Social Security #
E-mail Address
Single Married Widowed Separated Divorced Guardian
Employer
Employer Address
Employer Telephone

Complete if different from patient's home information:
Home Address
City
State
Zip
Home Telephone


Father
Name
Date of Birth	/ /
Social Security #
E-mail Address
Single Married Widowed Separated Divorced Guardian
Employer
Employer Address
Employer Telephone

Complete if different from patient's home information:
Home Address
City
State
Zip
Home Telephone

Dental Insurance Information

Primary Insurance
Orthodontic Coverage	Yes No
Company
Address
City
State
Zip
Insurance Telephone
Policy / Group #
Policy Holder's Name
Relationship to Patient


Secondary Insurance
Orthodontic Coverage	Yes No
Company
Address
City
State
Zip
Insurance Telephone
Policy / Group #
Policy Holder's Name
Relationship to Patient

Referral Information

How did you hear about us?
Name of person to thank for referral

DENTAL HISTORY

Patient's Dentist:
Date of Last Visit:
Have there been any injuries to the face, mouth or teeth? Yes No
Does the patient have any of the following habits? Thumb or finger sucking Lip Biting Snoring Grinding of teeth at night Mouth breathing No
Has the patient been informed of any missing or extra permanent teeth? Yes No
Has an orthodontist been consulted previously? Yes No Name: Date:
Has the patient ever been treated for: Bad Bite TMJ Periodontal disease No If so, by whom?
Does the patient have any speech problems? Yes No
Is there anything the patient would like to change about his/her smile? Yes No If so, what:
Reason for consultation:
Has there ever been any orthodontic treatment for any siblings? Yes No Name Doctor's Name

MEDICAL HISTORY

Is the patient's general health good at this time?
Yes No

Name of physician?
Date of last physical:

Is the patient under the care of a physician at this time?
Yes No
Explain:

Is the patient taking any medication?
Yes No
If yes, what:

Is the patient allergic to any medication? (Penicillin, Sulfa, etc.)
Yes No
If yes, what:

Does the patient have any other allergies (metals, latex, seasonal etc.)
Yes No
If yes, what:

Has the patient had tonsils and adenoids removed?
Yes No
Date:

Has the patient ever had a serious illness or been hospitalized?
Yes No
Date:
Explain:

Has the patient ever been advised by their physician to take an antibiotic prior to any dental treatments?
Yes No
If yes, antibiotic name and method:

Has the patient reached puberty?
Yes No

Is there any other information that should be known about your child to make their appointments more pleasant?

Does the patient have now or have they ever had any of the following?

Endocarditis	Yes No
Heart Condition	Yes No
Heart Pacemaker	Yes No
Heart Angina	Yes No
Heart Attack (coronary)	Yes No
Mitral Valve Prolapse	Yes No
Congenital Heart Disease	Yes No
Artificial Heart Valve	Yes No
Heart Surgery date:	Yes No
Heart Murmur	Yes No
Rheumatic Fever	Yes No
Prosthetic (artificial) Joint	Yes No
X-Ray/Radiation (cancer) Therapy	Yes No
AIDS or H.I.V. Positive	Yes No
Diabetes	Yes No
Respiratory Lung Disease	Yes No
High Blood Pressure	Yes No
Low Blood Pressure	Yes No
Hepatitis (type? )	Yes No
Tuberculosis	Yes No
Venereal Disease	Yes No
Herpes (oral-cold sores)	Yes No
Blood Disorders/Bleeding Problems	Yes No
Inflammatory Rheumatism	Yes No
Arthritis	Yes No
Ulcers	Yes No
Stroke	Yes No
Anemia	Yes No
Asthma	Yes No
Epilepsy	Yes No
Glaucoma	Yes No
Fainting Spells	Yes No
Kidney Trouble	Yes No
Liver Disease	Yes No
Psychiatric Treatment	Yes No
Drug Addiction	Yes No
Headaches	Yes No
Earaches	Yes No
Jaw Clicking	Yes No
Allergies	Yes No
Jaw Pain	Yes No
Tonsillitis	Yes No
Allergies to any metals	Yes No
Emotional Problems	Yes No
ADD	Yes No
PDD	Yes No
Developmentally Delayed	Yes No
Other:	Yes No

If you submit this form online, you will have a preprinted form ready for your signature at the time of your appointment.

Commerce Park Children's Dentistry & Orthodontics
Bridgeport • 4702 Main Street • (203) 371-8282 | Huntington • 27 Huntington Plaza • (203) 926-9929

Pediatric Dentists and Orthodontists for the Infants, Children and Teens of Fairfield County, Connecticut.