www.kennetortho.com

Child Registration Form

This form is for patients under the age of 18 years and must be completed and signed by a legal guardian of the patient

Patient Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Birthdate:
School:
Patient lives with:
Hobbies or interests:
Siblings
Name:
Birthdate:
Name:
Birthdate:
Name:
Birthdate:
Name:
Birthdate:
How did you hear about our office?

Parent / Guardian Information

Parent / Guardian #1
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Birthdate:
Social Security #:
Employer:
Occupation:
Length of Employment:
Relationship to Patient:
Legal guardian of patient?
Parent / Guardian #2
Signature:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Birthdate:
Social Security #:
Employer:
Occupation:
Length of Employment:
Relationship to Patient:
Legal guardian of patient?

Emergency Contact Information

Name of nearest relative not living with you:
Relationship to Patient:
Emergency Contact Phone:
This phone number is a:

Dental Insurance

Primary

Policy Holder's Name:
Birthdate:
Insurance Company Name:
Contract/SS Number:
Group Number:
Insurance Company Phone:

Secondary

Policy Holder's Name:
Birthdate:
Insurance Company Name:
Contract/SS Number:
Group Number:
Insurance Company Phone:

Dental History

Dentist Name:
Date of Last Visit:
Address/City:
Phone #:
What concerns you most about the patient's teeth (reason for your visit)?
Please select 'Yes' or 'No' (if yes, please provide details). Cannot be blank.
*
Is the patient experiencing any dental pain?
*
Have there been any injuries to face, mouth, or teeth?
*
Does patient have any thumb-sucking or tongue habits?
*
Has patient ever seen an orthodontist? If yes, who and when?
*
Has anyone in your family received orthodontic treatment?
*
Are you aware of patient's jaw clicking or popping?
*
Are you aware of patient clenching their teeth during the day?
*
Does patient have tension headaches?
*
Has patient ever experienced chronic ringing in their ears?
*
Does patient have a fear of the dentist?

Medical History

Physician Name:
Date of Last Visit:
Address/City:
Phone:
Please select 'Yes' or 'No' (if yes, please provide details). Cannot be blank.
*
Is patient allergic to Latex?
*
Is patient taking any medication? If yes, please list and indicate what each is taken for.
*
Are there any medication allergies?
*
Is there a history of a major illness?
*
Is there a history of major operations?
*
Is there a history of a serious accident?
Is patient pregnant?
Please select 'Yes' if patient has had or currently has any of the following medical conditions. Cannot be blank.
Abnormal bleeding / Hemophilia?
Arthritis?
Asthma / Hay fever?
Bone disorders?
Diabetes?
Dizziness?
Epilepsy?
Gastrointestinal disorders?
Heart defect?
Heart murmur?
Heart problems?
Hepatitis / Liver problems?
Herpes?
High blood pressure?
HIV / AIDS?
Kidney problems?
Nervous disorders?
Pneumonia?
Prolonged bleeding?
Radiation / Chemotherapy?
Rheumatic fever?
Tuberculosis?
Tumor or cancer?
If you answered yes to any question, please give details here:
Please detail any medical or mental conditions not mentioned above:
*
Does patient have learning disabilities or need assistance with instructions?

HIPAA

Effective April 14, 2003 the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review of entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgment / Consent

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and health care operations. Any electronic communication may not be secure.

Parent / Guardian:
Relationship to Patient: