Under 18 Orthodontic New Patient Form
Today’s Date ________________
Patient’s Last Name _______________________________ First _______________________ MI ______
DOB: ______________ Age: __________ Sex: ________ “I Prefer to be called ___________________”
Home Ph. #: __________________ Cell Ph. #: ________________ Work Ph. #: _____________________
Email Address/es: ________________________________________________________________________
Best Method for Appt. Confirmations (circle): EMAIL Home Ph. Cell Ph. Work Ph. Cell Text
Patient’s Full Address: ____________________________________________________________________
Legal/ Custodial Parent(s) or Guardian(s): _________________________________________________
Does Patient Live with Both Parents? Y/N : ______________________________________________________________
Other Family Members Treated Here: __________________________________________________________________
Person Financially Responsible for this Patient Account: ____________________________________
Address of Person Financially Responsible: ________________________________________________
Does Patient have Insurance Coverage for Orthodontic Treatment? _________________________
PRIMARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
SECONDARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
Did your Dentist Recommend Orthodontic Treatment? Yes _____ or No _____
How did you hear about Family Orthodontics at KidZdent? ______________________________________________
Dentist Name: ________________________________ Town: _______________________ Ph. #: ____________________
Date Last Seen by Dentist and Reason for Visit: _________________________________________________________
Do you have any dental treatment that needs to be done? _____________________________________________
Tell us a little bit about the Patient…
• What school/ grade does Patient attend? ___________________ Hobbies/ Sports?: ______________________
• What concerns you most about their smile? _________________________________________________________
• Are there other family members with the same condition? ___________________________________________
• What types of braces are you interested in? Traditional ___ Clear ___ Invisalign ___
• Is there a target date you expect treatment to be completed by? ___________________________________