Registration Children & Teens

Children & Teens Registration | Just Smile Orthodontics
Welcome to Just Smile Orthodontics, you have made a great choice coming to our office! Our goal is to make every client's visit pleasant and educational. For your convenience, we have met all privacy requirements on a SSL secure server. To save you time on your first visit, please fill them out completely (even fields that are not required). We look forward to seeing you! Dr. Leo & Staff.
Child's name

First NameLast Name
Child's birth date

MonthDayYear
Sex
Child's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Child's general dentist
Last exam date
Whom may we Thank for referring you?
Parent's Information
MOTHER
Relationship
Mother's name

First NameLast Name
Mother's birth date

MonthDayYear
Mother's e-mail
Mother's Cell phone

Area CodePhone Number
Mother's work phone

Area CodePhone Number
Mother's employer
How long at current job?
Mother's Social security #
Mother's address is the same as child's?
Mother's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
FATHER
Relationship
Father's name

First NameLast Name
Father's birth date

MonthDayYear
Father's e-mail
Father's phone number

Area CodePhone Number
Father's work phone

Area CodePhone Number
Father's employer
How long at current job?
Father's Social security #
Father's address is the same as child's?
Father's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
WHO IS ACCOMPANYING THE CHILD TO THE APPOINTMENT?
Full name

First NameLast Name
Relation
Do you have legal custody of this child?
Person responsible for account
Who is person responsible for account?
Responsible's name

First NameLast Name
Relation
Responsible's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Responsible's phone

Area CodePhone Number
Responsible's work phone

Area CodePhone Number
Responsible's Social security #
Responsible's employer
Primary dental insurance
Does the patient have dental or orthodontic coverage?
Who is the policy owner of the primary dental insurance?
Policy owner's name

First NameLast Name
Policy owner's birth date

MonthDayYear
Relationship to patient
Insurance ID # or Social security #
Group #
Insurance co. name
Insurance co. phone

Area CodePhone Number
Secondary dental insurance
Does the patient have secondary dental insurance?
Who is the policy owner of the secondary dental insurance?
Policy owner's name

First NameLast Name
Policy owner's birth date

MonthDayYear
Relationship to patient
Insurance ID # or Social security #
Group #
Insurance co. name
Insurance co. phone

Area CodePhone Number
Medical History
Patient’s family doctor, pediatrician or nurse practitioner name
Phone Number

Area CodePhone Number
Does the patient usually take antibiotics prior to dental treatment?
Is the patient currently taking medication or drugs?
Please list all medication and/or drugs that the patient is currently taking

Does the patient have any of the following?

Rows	Yes	No
abnormal bleeding
Artificial joints/valves
Arthritis
Asthma
Any hospital stays
Any surgery
Cancer
Congenital heart defect
Diabetes
Epilepsy/seizures
Hearing impairment
Heart problems
Frequent headaches
HIV/AIDS
Jaw/Head injuries
Kidney/Liver problems
Rheumatic/Scarlet fever
Special needs
Tuberculosis

Does the patient have any other serious condition?
Please list serious medical condition(s)

Is the patient allergic to any of the following?

Rows	Yes	No
Aspirin
Jewellery/Metal
Dental anesthetics
Penicillin
Latex

Please list any comments, other drugs or things you (or your child) is allergic to.
Dental History

Does the patient have:

Rows	Yes	No
Any Missing teeth?
Extra teeth?
Clenching/Grinding issues?
Mouth breathing habit?
Thumb/Finger sucking habit?
Clicking/Popping/Pain when opening jaws?
Brush daily?
Teeth sensitive to cold/hot?
Has patient seen an orthodontist?
Would the patient mind wearing braces?
Has the patient been ridiculed (made fun of) about the appearance of his/her teeth?
Has a dentist ever placed a retainer or space maintainer?
Have there been any injuries to the face, mouth, teeth or chin?

For children & adolescents only:

Rows	Yes	No
Has puberty been reached (i.e. start of menstruation or voice change)?
If so has it been the last 2 years?

What are the patient's main concerns that patient would like Dr. Leo Toureno to address?
Parent's/Guardian's reason for wanting patient to have orthodontic treatment?
The information, health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental/orthodontic services agreed between doctor and patient to be necessary or advisable. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication changes I will, without fail, inform the doctor at my next appointment.
e-Signature
Today's date

MonthDayYear
Should be Empty:

Children & Teens Registration | Just Smile Orthodontics

Parent's Information

Person responsible for account

Primary dental insurance

Secondary dental insurance

Medical History

Dental History