Step 1 of 7 14% WELCOME TO CC BRACESCHILD'S INFORMATIONChild’s Full Legal Name*Preferred Name*Date of Birth* MM DD YYYY Gender*MaleFemaleResidence Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is with child today?*Parent(s)Step-parentOtherPrimary Phone*Email* Whom may we thank for referring you to our office? Father’s InformationRelationship with Father*FatherStep FatherNot ApplicableOtherOther*Marital Status*SingleMarriedDivorcedWidowedFather's Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Text reminders OK?*YesNoWork PhoneEmployer(Name of Business if Self Employed)OccupationNo. years at EmployersSocial Security #*Date of Birth* MM DD YYYY Active Duty*YesNoMilitary Rank/RateDuty StationRetirement or Rotation Date MM DD YYYY Mother's InformationRelationship with Mother*MotherStep MotherNot ApplicableOtherOther*Marital Status*SingleMarriedDivorcedWidowedMother's Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Text reminders OK?*YesNoWork PhoneEmployer(Name of Business if Self Employed)OccupationNo. years at EmployersSocial Security #*Date of Birth* MM DD YYYY Active Duty*YesNoMilitary Rank/RateDuty StationRotation or Retirement Date MM DD YYYY Insurance InformationDental Insurance CardDental coverage under Father?*YesNoOrthodontic Coverage?*YesNoDon't knowInsurance Company Name*Member ID or SS#*Group Name/ NumberDental coverage under Mother?*YesNoOrthodontic Coverage?*YesNoDon't KnowInsurance Company Name*Member ID or SS#*Group Name / NumberEmergency Informationof the nearest relative not living with youName Contact Name*Phone Number* School, hobbies and additional informationSchool nameGradeMusical instrument(s) currently playingPersonal Interest or Hobbies:Name & Ages of Siblings: Medical/Dental InformationGeneral DentistGeneral dentist name*Date of Last exam* MM DD YYYY Family PhysicianMedical DoctorDate of Last Exam MM DD YYYY Under care of doctor now?YesNo Dental/Medical HistoryHas child been to an orthodontist before?*YesNoPlease specify*Have other family members had orthodontic treatment?*YesNoPlease specify*What are the main concerns have about your child’s teeth?*Does or did your child suck his/her fingers or thumb?*YesNoDoes your child breathe through mouth?*YesNoDoes your child have speech problems?*YesNoHas your child had serious injury to the face, mouth, or teeth?*YesNoPlease specify*Does/did child have missing/extra teeth?*YesNoDoes child clench/grind teeth?*YesNoDoes child have headaches?*YesNoDoes child have pain when opening or closing mouth?*YesNoHas child had a negative reaction to dental or medical care?*YesNoPlease specify*Medications being taken now*Type NA if noneHas your child experienced?* Blood Disorders? Drug Allergies? Allergic to latex/metals? Allergic to plastic? Any operations? Asthma? Cancer? Convulsions/Epilepsy? Diabetes? Hearing Impairment? Hepatitis? HIV/AIDS? Kidney/Liver Problems? Rheumatic/Scarlet Fever? Tuberculosis? Congenital Heart Defect? None Allergies*Type NA if nonePlease discuss any medical problems that your child has that might have an effect on his/her treatment in our office.For growth purposes, has your child gone through puberty?*YesNoDon't knowOur office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.This office reserves the right to verify the credit status of parents of potential patients prior to setting up financial arrangements.History given by*(self, parent or legal guardian name)Signature*Date