Patient Information
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Caples & Robinson Orthodontics
New Patient Form (Child)
Patient Information
Patient's Name
Preferred Name/Nickname
Birthdate
Age
Mother
Occupation
Father
Occupation
Guardian
Occupation
Your concerns we can discuss
School
Grade
Extracurricular activities, sports, etc.
Any prior orthodontic treatment?
Yes
No
If yes, what orthodontic treatment has been performed previously?
Has anyone in your immediate family been in the office for treatment?
Dentist
Date of last cleaning
Address
Home Phone
Social Security #
Have we treated other family members?
Yes
No
Family member(s) we have treated:
Name of the family member we have treated:
Relationship to patient:
Add more
Whom may we thank for referring you to our office?
Physician Name
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Caples & Robinson Orthodontics
New Patient Form (Child)
Custodial Parent or Guardian Information
Name
Relationship to patient:
Email
Social Security #
Birthdate
Employer
Occupation
Number of Years Employed
Home Phone
Work Phone
Cell Phone
Residence
Does the patient live at this address?
Yes
No
How long have you resided at this address?
Please select
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
More than 10 years
Please select
Previous Address (if less than 3 years)
Do you have a different
mailing
address?
Yes
No
Mailing Address
Do you have a spouse?
Yes
No
Spouse's Name
Spouse's relationship to patient:
Spouse's Employer
Spouse's Occupation
# of Years Employed (Spouse)
Spouse's Social Security Number
Spouse's Birthdate
Spouse's Cell Phone
Spouse's Work Phone
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Caples & Robinson Orthodontics
New Patient Form (Child)
Insurance Information
Insured's Name
Social Security #
Date of Birth
Insurance Company
Group Number
Insurance Company's Address
Insurance Company's Phone Number
Do you have dual coverage?
Yes
No
Insured's Name
Insurance Company
Group Number
Insurance Company's Address
Insurance Company's Phone Number
I hereby authorize payment directly to Caples & Robinson Orthodontics of the group insurance benefits otherwise payable to me:
Sign Below
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Caples & Robinson Orthodontics
New Patient Form (Child)
Appointment Information
I am aware that orthodontic appointments must be scheduled during school and/or work hours. We know your time is valuable and we strive to complete your appointment in a timely manner, being on time will help us achieve this:
Sign Below
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Caples & Robinson Orthodontics
New Patient Form (Child)
Medical Information
Are there any medical conditions we should be aware of?
Yes
No
Do you have experience with any of the following medical conditions?
Please check all that apply
Heart Disease
Blood Disease
Thyroid Disease
Bone Disease
Emotional or Nervous Problems
Endocrine Problems
Problems with Wound Healing
Asthma
Diabetes
Epilepsy
Heart Murmur
Hemophilia
Hepatitis
HIV Positive
Mitral Valve Prolapse
Artificial Joints or Heart Valves
Mononucleosis
Prolonged Bleeding
Rheumatic/Yellow/Scarlet Fever
Rheumatism or Arthritis
Tuberculosis
Are you under medical care?
Are you in bad health?
Are you pregnant?
Do you smoke tobacco?
Have you ever taken bisphosponates?
Are you allergic to anything?
Are you aware of any other disease, condition, or problem not listed that we should know about?
N/A
Please list your allergies:
Please list any additional diseases, conditions, or problems not previously listed that apply to you:
Please list any and all medications you are currently taking:
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Caples & Robinson Orthodontics
New Patient Form (Child)
Dental History
Do any of the following scenarios apply to you?
Please check all that apply
Have you seen a General Dentist in the last year?
Has the mouth, face, or teeth been injured by a fall or accident?
Have you been informed of missing or extra permanent teeth?
Are you aware of any "gum" or periodontal problems?
Has a physician or dentist advised antibiotics before a dental exam?
Have your tonsils or adenoids been removed?
Any clicking or popping of the jaw?
Any jaw discomfort or pain?
N/A
Do you have or ever had any of the following habits?
Please check all that apply
Thumb sucking
Finger nail biting
Clenching or grinding teeth
Tongue thrusting
Speech problems
N/A
Have you been examined by an orthodontist before?
Yes
No
When were you last examined by an orthodontist?
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Caples & Robinson Orthodontics
New Patient Form (Child)
Information Confirmation
I certify that the information on this form is correct. I understand that it is my responsibility to report any changes and that where appropriate, credit bureau reports may be obtained.
Signature of Patient
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Caples & Robinson Orthodontics
New Patient Form (Child)
HIPAA
Acknowledgement of Receipt of Notice of Health Information Privacy Practices
Patient Name
I acknowledge receipt of this Notice of Health Information Privacy Practices.
Patient/Responsible Party Signature
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Verification
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