New Patients (Child) |

Patient Information

Patient's Name

Age

Birthdate

Nickname

Patient's Home Phone

Sex

Male
Female

Patient's Home Address

Street Address City State ZIP Code

School

Who is filling out this form?

Name

Relationship

Do you have legal custody?

Yes
No

How did you hear about our office?

Have we treated another member of your family?

Yes
No

Name of family member

If your child is being seen for an Orthodontic appointment:

What are the main concerns that you would like orthodontics to accomplish?

Has your child visited an orthodontist before?

Yes
No

For what reason?

Date of last visit

X-rays recently?

Yes
No

Father's Information

Name

Father
Stepfather
Guardian

Marital Status

Birthdate

Is your home address different from child's?

Yes
No

Father's Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Work Phone

Social Security Number

Employer

Email

Mother's Information

Name

Mother
Stepmother
Guardian

Marital Status

Birthdate

Is your home address different than child's?

Yes
No

Mother's Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Work Phone

Social Security Number

Employer

Email

Insurance

Insurance Company Name

Group or Plan #

Insurance Company Phone #

ID #

Insurance Company Address

Street Address City State ZIP Code

Insured's Name

Insured's Birthdate

Relationship

Insured's SS#

Insured's Employer

New Patient Info (Child)

Patient Information

Who is filling out this form?

If your child is being seen for an Orthodontic appointment:

Father's Information

Mother's Information

Insurance

Smiles of Dripping Springs

Services

Smiles of Austin

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