Child Orthodontics Lyndhurst

Child New Patient Orthodontics Form

Please complete the form below before your first visit

Child holding retainer and braces prop
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Patient Name
Patient Last Name
Parent/Guardian E-Mail
Parent/Guardian Phone Number
Patient's School
Patient's Grade
Please list the patient's sports and extracurricular activities:
Please list any siblings and their DOB:
Patient Social Security Number
Patient Date of Birth
Full Mailing Address
Patient's General Dentist
Patient's Last General Dentist Visit Date
Parent's Employer Name
Parent's Occupation
Dental Insurance Company
Insurance Phone Number
Policy Holder's Name
Policy Holder's Date of Birth
Relationship to Policy Holder
Policy Holder's SSN
Medical ID Number
Group Number
Partner's Name
Partner's Phone Number
Is it okay to release appointment and medically related information concerning your child to your partner?
Does the patient have or ever had any of the follow? (select all that apply)
Has the patient ever had an injury to: (select all that apply)
Does the patient currently have or ever had any of the following habits? (select all that apply)
Does the patient have any trouble with sleeping or snoring?
Has the patient had their tonsils or adenoids removed?
Has the patient ever experienced jaw joint pain or discomfort? (TMJ/TMD)
Does the patient have speech problems?
Does the patient's gums bleed?
Does the patient smoke?
Does the patient like to smile?
What are the main concerns you or the patient would like an orthodontist to accomplish?
Has the patient visited an orthodontist before? If so, when and why?
Is the patient currently being treated by a physician? If yes, please include the physician's name, number, reason for treatment, and most recent treatment date.
Does the patient have any allergies or sensitivities to medications or latex? If yes, please list all allergies.
Does the patient currently take any prescription or over-the-counter medications? If yes, please list with dosage.
Has the patient had any serious illness or operations? If yes, please describe.
How did you hear about us?
Full Name
Date
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440-449-5792
29001 Cedar Rd,
Lyndhurst, OH 44124
We’re welcoming new patients and can’t wait to meet you.
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