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Online Child Information Form

Online Child Registration Form

Patient Information (Child)




Parent or Guardian Information

Parents' Marital Status
1st Parent or GuardianMotherGrandmother 

Name: Birth Date: Address (if different): City: State: Zip Code: 

Phone Number (if different): HomeCell

E-mail Address: 

2nd Parent or GuardianMotherGrandmother 

Name: Birth Date: Address (if different): City: State: Zip Code: 

Phone Number (if different): HomeCell

E-mail Address: 

Employer's Name: Occupation: 

Insurance Information





Dental History

How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Has your child visited an orthodontist before?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply)?





Medical History

Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has your child had any serious illnesses or operations? Yes
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

Authorization

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's 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.



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Cook & Mess Orthodontics

  • Columbus - 4775 Knightsbridge Blvd., Suite 201, Columbus, OH 43214 Phone: 614-457-6567
  • Upper Arlington - 2060 Arlington Ave., Columbus, OH 43221 Phone: 614-457-6567

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