Allen

McKinney

Child new patient form

Welcome to Creekview & McKinney Orthodontics

We appreciate you filling out this form completely before your first visit. Please contact us if you have any questions.

"* (Required)" indicates required fields

Today's Date* (Required)

In which office will we be seeing you?* (Required)

(Office use only: #)

Patient Information

First Name* (Required)

Middle Initial

Last Name* (Required)

Nickname

Date of Birth* (Required)

Age* (Required)

Address* (Required)

Street Address City State / Province / Region ZIP / Postal Code

Parent/Guardian Phone* (Required)

Parent/Guardian Email* (Required)

Gender* (Required)

Patient's Brothers (if any) - Names and Ages* (Required)

Patient's Sisters (if any) - Names and Ages* (Required)

School* (Required)

Grade* (Required)

Hobbies & interests* (Required)

Has any member of the patients family undergone orthodontic treatment?* (Required)

Yes

If yes, which family member?

If yes, are they currently in orthodontic treatment?

Yes

If yes, when did they start treatment? Date of last appointment?

Who was their orthodontist?

Who may we thank for referring you?* (Required)

What does the patient not like about their teeth? (Reason for seeing us)* (Required)

Patient's Dentist* (Required)

Date of last dental exam (Approximately)* (Required)

Date of last dental cleaning (Approximately)* (Required)

Is the patient in good health?* (Required)

Yes

Have tonsils and adenoids been removed?* (Required)

Yes

Has patient ever sucked thumb or finger?* (Required)

Yes

Is the patient a mouth breather?* (Required)

Yes

Does the patient have any speech problems?* (Required)

Yes

If yes, please explain speech issue(s):

Does the patient play a wind instrument?* (Required)

Yes

Does the patient have any discomfort in the jaw joints?* (Required)

Yes

If yes, please describe jaw discomfort:

If patient is female, is she post-pubertal?

Yes

If patient is female, is she pregnant?

Yes

Please list any allergies or drug sensitivities:* (Required)

Has the patient ever had any of the conditions listed below?* (Required)

Yes

(If yes, please check box below and elaborate)

If yes, please describe:

Dental Insurance (not Medical) *Primary

(Note: we will file a claim for your secondary insurance, but will accept payments from one carrier only).

Insurance Co. Name & Tel.* (Required)

Insurance Company State* (Required)

Policy Holder Name & Insurance ID # (SSN if no ID) (For Insured Patient)* (Required)

Group Number (For Insured Patient)* (Required)

Employer Name & Address (of Policy Holder)* (Required)

Primary Responsibility Party Information

Relationship to Patient* (Required)

First Name* (Required)

Middle Name

Last Name* (Required)

Address* (Required)

Street Address City State / Province / Region ZIP / Postal Code

Number of years at the above address* (Required)

Previous Address (if less than 3 yrs at current address)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone* (Required)

Work Phone

Dental Insurance ID # (Not Medical) (SSN if no ID)* (Required)

Email* (Required)

Date of Birth* (Required)

Employer* (Required)

Occupation

No. of Years Employed

Secondary Responsibility Party Information

Relationship to Patient

First Name

Middle Name

Last Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years at the above address

Previous Address (if less than 3 yrs at current address)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Dental Insurance ID # (Not Medical) (SSN if no ID)

Date of Birth

Employer

Occupation

No. Years Employed

Consent & Acknowledgement of Receipt of Notice of Privacy Practices

*You reserve the right to refuse this acknowledgement*

I have read and understand the above questions. I will not hold this office responsible for any errors or omission in the completion of this form. If there are any changes later to the history form or the health status, I will so inform this practice. I also certify that I (or my dependent) assign my insurance benefits directly to Dr. Ghosh and Dr. Lofgren, otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that where appropriate, credit bureau reports may be obtained.

I have read, understood and agree to the Privacy Policy

Parent’s signature* (Required)

Date* (Required)

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