CCbraces Child Registration 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*

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*

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*

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*

Medical Information
Type NA if none
General Dentist
Dentist Doctor's Name*
Office Phone
Date of Last cleaning/checkup*
Family Physician
Physician Doctor's Name
Office Phone
Date of Last Exam
Dental/Medical History
Type NA if none
What concerns do you have about your child’s teeth/smile?*
Has your child been seen by orthodontist?*
- Yes
- No
- Don't know
When*
Has anyone in your family had orthodontic treatment?*
- Yes
- No
- Don't know
Please specify*
Is your child currently having dental treatment or cleaning in the last year?*
- Yes
- No
- Don't know
Please specify*
Has your child experienced any complications following dental treatment?*
- Yes
- No
- Don't know
Please specify*
Has your child ever had instructions in proper brushing technique, gums bleed when brushed?*
- Yes
- No
- Don't know
Please specify*
Frequent canker sores or cold sores? Teeth causing irritation to lip, cheek of gums?*
- Yes
- No
- Don't know
Please specify*
Does your child frequently breathe through his/her mouth? Or snore?*
- Yes
- No
- Don't know
Please specify*
Did your family member’s orthodontic treatment include jaw surgery or tooth extractions?*
- Yes
- No
- Don't know
Please specify*
Has your Child ever injured his/her jaw, face or teeth?*
- Yes
- No
- Don't know
Please specify*
Does or did your child suck his/her fingers or thumb?*
- Yes
- No
- Don't know
Please specify*
Does your child have any other dental problems, abnormalities (extra) or (missing) teeth?*
- Yes
- No
- Don't know
Please specify*
Any soreness in jaw muscles? tooth grinding or clenching? Clicking, locking in jaw joints?*
- Yes
- No
- Don't know
Please specify*
Who suggested that you might need orthodontic treatment?*
Why did you select our office?*

Diseases / Allergies
Have you ever had or been treated by a physician for*
- Heart disease or defects, Murmur
- Birth defects, Hereditary problems
- Immune systems problems
- Rheumatic Fever
- Diabetes or low sugar
- Abnormal Bleeding/Hemophilia
- Kidney Disease
- Hepatitis, Liver Disease
- AIDS/HIV+
- Eating disorder, anorexia, bulimia
- Arthritis or joint problems
- Seizures, fainting spells, neurologic problems
- High or Low blood pressure
- Tuberculosis, mononucleosis
- Frequent ear, throat infections
- Vision or Hearing Problems
- Tonsils/Adenoids/Sinus Problem
- Eye Problems/Contact Lenses
- Mental Health/Depression
- Do you eat a well-balanced diet
- Headache/Migraines
- Cancer, Tumor, Chemotherapy, Radiation Therapy
- Endocrine/Thyroid Problems
- Skin disorder
- Artificial Joints/Valves
- Bone Fractures, major injuries
- Osteoporosis, bone disorder
- Stomach ulcer, acid reflux
- Asthma, sinus, hayfever
- Polio, tuberculosis, mononucleosis
- Autism Spectrum Disorder
- Emotional/Behavior Problems
- Attention Deficit Disorders
- NONE
- Other
Have you had allergies or reactions to any of the following*
- Local anesthetics (novocaine, lidocaine, xylocaine)
- Latex (gloves, balloons) Plastic
- Aspirin or ibuprofen )Motrin, Advil)
- Metals (jewelry, clothing snaps)
- Acrylics
- Penicillin, Other antibiotics
- Plant pollens, Animals
- Food
- Other substances
- NONE
Food list*
Other substances List*
Is antibiotic premedication required before dental procedures?*
- Yes
- No
Please list any medical problems you have that might have an effect on your treatment in our office*
Enter NA if not applicable
List all current medications, and any additional comments…*
Enter NA if not applicable
Has your child reached puberty (menstruation, voice change, hair growth)?*
- Yes
- No
- Don't know
Has your child had any recent rapid growth?*
- Yes
- No
- Don't know
If yes, how much?
Release and Waiver*
I authorize release of any information regarding my child’s orthodontic treatment to my dental and or medical insurance company.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form.
I will notify my orthodontist of any changes in my child’s medical or dental health
Signature of Patient or Legal Guardian*
Date

HIPAA Policy
Privacy Policy*
PRIVACY POLICY

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I have clicked the link above and read the document.
Signature*
Date

Authorization to Release Patient Record Information
I hereby authorize CC Braces to disclose facial and/or dental photographs, photographs, and video of the following patient as approved below:*
- Yes
- No
May the patient's picture be displayed on the reception computer screen for patient sign-in purposes?*
- Yes
- No
May the patient's picture be displayed on the office website, Blog, Social Media accounts and/or within the office for the purpose of informing patients of the positive outcome we have achieved?*
- Yes
- No
May the patient's picture be displayed on the office website, Blog, Social Media account and/or within the office if they are a contest prize winner?*
- Yes
- No
May the patient's records including photographs be used for the purposes of professional consultations, research, education or publication in professional journals?*
- Yes
- No
Please Note*
Financial Disclosure: I understand that the practice is not receiving compensation from anyone for use of the patient's photo.

Refusal to Sign: I understand that refusal to sign part or all of this Authorization will in no way affect the patient's treatment.

Revocation: I understand that I may revoke this authorization at any time by sending a written notice to the practice. All photos will be removed at the time the revocation is received.
I certify that I am the authorized representative for the patient.
Signature of Patient or Legal Guardian*
Date
Dr. Colin Mihalik, DDS, MS
5525 S. Staples Bldg. C Corpus Christi, Texas 78411