Boschken Orthodontics Forms, Los Altos CA

Child or Teen Patient Form

We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

This is a secure form.

Patient Information

Patient's Name:

First

Middle

Last

Nickname (if preferred):

Male Female

Age:

BDay:

Home Phone:

Cell Phone:

Home Address:
Email:

Who is filing in this form? (name):
Relationship:
Do you have legal custody?	YES NO
General Dentist:

How did you hear about our office?
Have we treated another member of your family?	YES NO If YES, Name:
What are the main concerns that you would like orthodontics to accomplish?
Have your child visited an orthodontist before?	YES NO If YES, for what reason?:
Anything you would like to discuss with the doctor in private?	YES NO

Parents Information

Marital Status:

Single Married Widowed
Divorced Separated Domestic Partner

Father:

Relationship:	Father Step Father Guardian
Name:
Address: (if different than child's)

Home Phone:
Work Phone:
Cell Phone:
SS#:
BDay:

Employer:
Employer Address:
Employer #:

If you have insurance coverage for the child, please fill out.

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan#:

Mother:

Relationship:	Mother Step Mother Guardian
Name:
Address: (if different than child's)

Home Phone:
Work Phone:
Cell Phone:
SS#:
BDay:

Employer:
Employer Address:
Employer #:

If you have insurance coverage for the child, please fill out.

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan#:

Dental and Medical History

Is your child currently under the care of a physician?	YES NO If YES, for what reason?:
Child's Physician:
Phone#:
History of major illness?	YES NO If YES, please describe:
Any sensitivities or allergies?	YES NO If YES, please describe:
Currently taking any medications?	YES NO If YES, please describe: Amount/Dose:
Has Puberty Begun?	YES NO
Has Menstruation (period) begun?	YES NO NOT APPLICABLE

Have your child been treated for any of the following?

Arthritis
Asthma
Blood Disorder
Cancer
Diabetes

Epilepsy
Heart Condition
Nervous Disorder
Tuberculosis

Does your child require antibiotics before dental treatment?	YES NO If YES, explain:
Have the adenoids or tonsils been removed?	YES NO
Have you been informed of any missing or extra permanent teeth?	YES NO
Have there been injuries to your child's face, mouth or chin?	YES NO
Has your child ever had pain/tenderness in your jaw joint (TMJ/TMD)?	YES NO

Does/Did your child have any of the following habits?

Grinding Teeth
Mouth Breather
Finger/Thumb Sucking

Speech Problems
Prolonged Bottle/Pacifier
Chewing/Eating Problems

(required) - I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.