Child Treatment Form

Parent / Guardian Information

Parent 1

Social Security Number:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Parent 2

Social Security Number:

Birth Date:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release medically-related information regarding your child to:

Relation(s) to Child:

Dental Insurance

Dental Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Dental Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

* General Dentist:

* Last Visit:

* How often does your child brush?

* How often does your child floss?

Has your child visited an orthodontist before? Yes No

If yes, when?

Reason:

Have we treated any other family members? Yes No

If yes, please name:

Medical History

* Does your child pre-medicate with antibiotics prior to dental procedures? Yes No

Is your child currently being treated by a physician? Yes No

Reason:

* Patient’s Physician:

* Last Visit:

* Phone:

* Does your child have any diagnosed or suspected emotional, sensory, or developmental conditions? Yes No

If yes, please list:

* Does your child have any allergies/sensitivities to medications, metal, or latex? Yes No

If yes, please list:

* Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has your child had any serious illnesses or operations? Yes No NA

If yes, describe:

If yes, give approximate dates:

* Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate)? Yes No

* Has your child ever taken oral medication for bone disorders or cancers such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate)? Yes No

* FOR WOMEN (select all that apply) Menstruation has begun Currently pregnant Currently nursing Currently taking birth control pills N/A

Submission Statement

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I understand the release of any information pertaining to my medical treatment may be necessary to process any insurance claims and that Weisner Orthodontics may submit the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Submitted by:

Date:

Child Treatment Form

Patient Information

Parent / Guardian Information

Parent 1

Parent 2

Emergency Contact Information

Dental Insurance

Secondary Insurance

Dental History

Medical History

Submission Statement

Methuen Office

North Andover Office

Contact Us

Quick Links

Follow Us