CHILD INFORMATION

Your name ___________________________ Preferred name __________________ M/F

Address ______________________________ __ZIP________ Home phone_____________

School_______________________ Grade______ Birthdate ______________ Age_______

Do you have any relatives that we’ve seen in our office before?_________________

Name of General Dentist________________________ Date of last visit _____________

How do you feel about wearing braces? _______________________________________

Do you have friends that wear braces? ________________________________________

What is your primary concern for today’s visit? _______________________________

______________________________________________________________________________

Whom may we thank for referring you to our office? ___________________________

Which office is most convenient for you? San Clemente? San Juan Capistrano?

FAMILY INFORMATION

FATHER MOTHER

Name __________________________________ Name ___________________________________

Address ________________________________ Address _________________________________

_________________________________________ __________________________________________

How long at this address?_______Rent/own How long at this address? _______Rent/Own

Work phone _____________________________ Work phone ______________________________

Cell phone ______________________________ Cell phone _______________________________

Employer _______________________________ Employer ________________________________

Occupation _____________________________ Occupation ______________________________

Date of birth ____________________________ Date of birth _____________________________

Orthodontic insurance __________________ Orthodontic insurance ___________________

Insurance Co. Phone # __________________ Insurance Co. Phone # ___________________

Social Security #_________________________ Social Security # _________________________

FOR OFFICE USE: Benefits ______@____% FOR OFFICE USE: Benefits ________@ ___%

Deductible __________How paid __________ Deductible ___________ How paid _________

Used ___________Exclusions ______________ Used ____________ Exclusions_____________