Child New Patient Information
* required field

Child Patient Information


Patient Resides With:

Primary Phone Number: *

Patient Interests:

Parent/Guardian Information

Parent Marital Status:
Relationship: *

Primary Phone Number: *
Secondary Phone Number:


Primary Phone:
Secondary Phone:

Insurance Information

Please bring the patient's dental insurance card(s) or a copy of the front and back of the dental insurance card(s) with you to the exam appointment.

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your dental care. All information will be kept completely confidential.

Medical History

Has your child experienced any health problems?
Any major change in your child's health recently?
Is your child currently under a physician's care?
Is your child currently taking medications?
Is your child allergic to any medications?
Has your child received a blood transfusion?

Have your child's tonsils or adenoids been removed?
Has your child been in a risk group for AIDS?
Please check if your child has any of the following conditions

Growth Information for Patients Under 16 Years of Age

Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid in our selection of treatment alternatives:

Has your son or daughter reached puberty?
Girls-Has she started menstruation?
Boys-Has his voice changed?

Do you feel growth is completed?

Names and Birthdates of Patient's Brothers and Sisters:
Have either siblings or parents had orthodontic treatment?

Dental History

Frequency of dental checkups:
Is there any unfinished care to be completed with your child's dentist?

Is your child frightened about dental treatment?

Has you child had an unpleasant experience in a dental office?

Has your child had any face or dental injuries?

Is there any history of thumb or finger sucking?

Does your child play any musical instruments?

Has your child consulted an orthodontist previously?

Have teeth (either primary or permanent) been removed?
Has your child had any previous orthodontic treatment?

Are you satisfied with prior treatment?

Please check if there is a history of:
Is there any other information that may be helpful?


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 hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize 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. I understand that where appropriate, credit bureau reports may be obtained. I also acknowledge that I have received or have been give the opportunity to receive a copy of Casey Sayre Orthodontics Notice of Privacy Practices. By signing below I am giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices. 

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