WELCOME TO OUR OFFICE

positiveIn an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

This is a secure form.

Which location would you prefer?

 Los Altos San Jose

Patient Information...

First Name:
Last Name:
Nickname (if preferred):
Gender:  Male Female
Home Phone:
Cell Phone:
Patient's Age:
Patient's Birthdate:
Email:
General Dentist:
Home Address:
Who is filling in this form?
Relationship:
Do you have legal custody?  Yes No
 
How did you hear about our office?
Have we treated another member of your family?  Yes No
If YES, Name:
What are the main concerns that you would like orthodontics to accomplish?
Has your child visited an orthodontist before?  Yes No
If YES, for what reason?
Anything you would like to discuss with the doctor in private?  Yes No

Parents Information...

Marital Status:  Single Married Widowed Divorced Separated Domestic Partner

Father:

Relationship:  Father Step Father Guardian
Name:
Home Phone:
Work Phone:
Cell Phone:
Address (if different than child's):
SS#:
BDay:
Employer:
Employer #:
Employer Address:

If you have insurance coverage for the child, please fill out.

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:

Mother:

Relationship:  Mother Step Mother Guardian
Name:
Home Phone:
Work Phone:
Cell Phone:
Address (if different than child's):
SS#:
BDay:
Employer:
Employer #:
Employer Address:

If you have insurance coverage for the child, please fill out.

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:

Dental and Medical History...

Is your child currently under the care of a physician?  Yes No
If YES, for what reason?
Physician:
Phone#:
History of major illness?  Yes No
If YES, please describe:
Any sensitivities or allergies?  Yes No
If YES, please describe:
Currently taking any medications?  Yes No
If YES, please describe:
Amount/Dose:
Has Puberty Begun?  Yes No
Has Menstruation (period) Begun?  Yes No Not Applicable
Has your child been treated for any of the following?  Arthritis Asthma Blood disorder Cancer Diabetes Epilepsy Heart Condition Nervous Disorder Tuberculosis
Does your child require antibiotics before dental treatment?  Yes No
If YES, explain:
Have the adenoids or tonsils been removed?  Yes No
Have you been informed of any missing or extra permanent teeth?  Yes No
Have there ever been injuries to your child's face, mouth or chin?  Yes No
Has your child ever had pain/tenderness in your jaw joint (TMJ/TMD)?  Yes No
Does/Did your child have any of the following habits?  Grinding Teeth Chronic Mouth Breathing Finger/Thumb Sucking Speech Problems Prolonged Bottle/Pacifier Chewing/Eating Problems
Please agree to the following...  (required) - I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.

OUR LOCATIONS:

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Los Altos Orthodontics:
86 Third Street, Suite 112
Los Altos, CA 94022

1-650-948-3994

Hours:

  • Mon 8:00 – 5:00
    (by apt only)
  • Tues 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Wed 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Thurs 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Fri 8:00 – 5:00
    (11:30 – 1:30 lunch)

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San Jose Orthodontics:

6128 Camino Verde Dr
San Jose, CA 95119

1-408-225-6660

Hours:

  • Mon 8:00 – 5:00
    (11:00 – 1:00 lunch)
  • Tues 9:00 – 4:00
    (by apt only)
  • Wed 9:00 – 5:00
    (12:00 – 2:00 lunch)
  • Thurs 8:00 – 5:00
    (12:00 – 2:00 lunch)