Adolescent Intake Form - Clinton Braces

1. About Your Child

Today's Date

First Name

MI

Last Name

Email

Child's Birthdate

Gender

Male Female

Street Address

Street Address Line 2

City

State

Zip Code

Grade

Best Phone Number

2. Accompanying Adult and Dentist

Accompanying Adult First Name

Accompanying Adult Last Name

Relationship to Child

Do you have custody of this child?

Yes No

Whom may we thank for referring you?

General Dentist

Last Dental Visit

When was your child's last dental cleaning?

3. Parent / Guardian and Responsible Party

Parent / Guardian 1

Relationship

First Name

Last Name

Email

Phone

Birthdate

Parent / Guardian 2 (if applicable)

Relationship

First Name

Last Name

Email

Phone

Responsible Party

First Name

Last Name

Relationship to Child

Phone

Is the address the same as the child's?

Yes No

4. Orthodontic Insurance

Do you have orthodontic coverage?

Yes No

5. Medical and Dental History

What are your concerns regarding your child's teeth?

Has your child previously had orthodontic treatment?

Yes No

Has your child ever had jaw pain, clicking, locking, or trouble opening or closing their mouth?

Yes No Not sure

Have there been any traumatic injuries to the face, mouth, or teeth?

Yes No

Does your child have any loose or moving permanent teeth (not baby teeth)?

Yes No Not sure

Has your child ever had permanent teeth removed?

Yes No

Does your child breathe through their mouth?

Yes No

Is your child currently under a physician's care?

Yes No

Child's Physician

Physician Phone

Has puberty started?

Yes No

Please describe your child's general health

Good Fair Poor

Please list all medications your child is currently taking

Please list any medical conditions your child has

Allergies (check all that apply)

Please discuss any conditions checked above

Emergency Contact Name

Emergency Contact Phone

6. Consult Questions

Has the patient already seen a general dentist, or do they need to see one first?

Already referred by general dentist Needs to see general dentist first

Are there any cavities or unfinished dental work still needing treatment?

Yes No

What kind of scheduling works best?

Weekdays are okay Weekdays only Saturday only

Does the patient have any tooth sensitivity or anything else the doctor should know? Type none if not.

Are you interested in aligners or comparing braces and aligners?

Braces only Aligners only Compare both Not sure

Language and Interpreter Support

The language of this form may be different from the language you prefer to speak. These answers help us prepare for your consultation.

What language do you prefer to speak during the consultation?

English / Ingles Espanol / Spanish Another language

Would you like a human interpreter during the consultation?

No Yes Not sure

Automated translation and a human interpreter are separate options.