CCbraces Child Registration Short Form

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WELCOME TO CC BRACES
CHILD'S INFORMATION
Child’s Full Legal Name*
Preferred Name*
Date of Birth*
Gender*
- Male
- Female
Residence Address*
Street Address City State ZIP Code
Who is with child today?*
- Parent(s)
- Step-parent
- Other
Primary Phone*
Email*
Whom may we thank for referring you to our office?

Father’s Information
Relationship with Father*
- Father
- Step Father
- Not Applicable
- Other
Other*
Marital Status*
- Single
- Married
- Divorced
- Widowed
Father's Name*
First Last
Address*
Street Address City State ZIP Code
Cell Phone*
Text reminders OK?*
- Yes
- No
Work Phone
Employer

(Name of Business if Self Employed)
Occupation
No. years at Employers
Social Security #*
Date of Birth*
Active Duty*
- Yes
- No
Military Rank/Rate
Duty Station
Retirement or Rotation Date

Mother's Information
Relationship with Mother*
- Mother
- Step Mother
- Not Applicable
- Other
Other*
Marital Status*
- Single
- Married
- Divorced
- Widowed
Mother's Name*
First Last
Address*
Street Address City State ZIP Code
Cell Phone*
Text reminders OK?*
- Yes
- No
Work Phone
Employer

(Name of Business if Self Employed)
Occupation
No. years at Employers
Social Security #*
Date of Birth*
Active Duty*
- Yes
- No
Military Rank/Rate
Duty Station
Rotation or Retirement Date

Insurance Information
Dental Insurance Card
Dental coverage under Father?*
- Yes
- No
Orthodontic Coverage?*
- Yes
- No
- Don't know
Insurance Company Name*
Member ID or SS#*
Group Name/ Number
Dental coverage under Mother?*
- Yes
- No
Orthodontic Coverage?*
- Yes
- No
- Don't Know
Insurance Company Name*
Member ID or SS#*
Group Name / Number
Emergency Information
of the nearest relative not living with you
Name Contact Name*
Phone Number*

School, hobbies and additional information
School name
Grade
Musical instrument(s) currently playing
Personal Interest or Hobbies:
Name & Ages of Siblings:

Medical/Dental Information
General Dentist
General dentist name*
Date of Last exam*
Family Physician
Medical Doctor
Date of Last Exam
Under care of doctor now?
- Yes
- No

Dental/Medical History
Has child been to an orthodontist before?*
- Yes
- No
Please specify*
Have other family members had orthodontic treatment?*
- Yes
- No
Please specify*
What are the main concerns have about your child’s teeth?*
Does or did your child suck his/her fingers or thumb?*
- Yes
- No
Does your child breathe through mouth?*
- Yes
- No
Does your child have speech problems?*
- Yes
- No
Has your child had serious injury to the face, mouth, or teeth?*
- Yes
- No
Please specify*
Does/did child have missing/extra teeth?*
- Yes
- No
Does child clench/grind teeth?*
- Yes
- No
Does child have headaches?*
- Yes
- No
Does child have pain when opening or closing mouth?*
- Yes
- No
Has child had a negative reaction to dental or medical care?*
- Yes
- No
Please specify*
Medications being taken now*

Type NA if none
Has 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 none
Please 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?*
- Yes
- No
- Don't know
Our 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