Step 1 of 8 12% 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* 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 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 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* Medical InformationType NA if noneGeneral DentistDentist Doctor's Name*Office PhoneDate of Last cleaning/checkup* MM DD YYYY Family PhysicianPhysician Doctor's NameOffice PhoneDate of Last Exam MM DD YYYY Dental/Medical HistoryType NA if noneWhat concerns do you have about your child’s teeth/smile?*Has your child been seen by orthodontist?*YesNoDon't knowWhen* MM DD YYYY Has anyone in your family had orthodontic treatment?*YesNoDon't knowPlease specify*Is your child currently having dental treatment or cleaning in the last year?*YesNoDon't knowPlease specify*Has your child experienced any complications following dental treatment?*YesNoDon't knowPlease specify*Has your child ever had instructions in proper brushing technique, gums bleed when brushed?*YesNoDon't knowPlease specify*Frequent canker sores or cold sores? Teeth causing irritation to lip, cheek of gums?*YesNoDon't knowPlease specify*Does your child frequently breathe through his/her mouth? Or snore?*YesNoDon't knowPlease specify*Did your family member’s orthodontic treatment include jaw surgery or tooth extractions?*YesNoDon't knowPlease specify*Has your Child ever injured his/her jaw, face or teeth?*YesNoDon't knowPlease specify*Does or did your child suck his/her fingers or thumb?*YesNoDon't knowPlease specify*Does your child have any other dental problems, abnormalities (extra) or (missing) teeth?*YesNoDon't knowPlease specify*Any soreness in jaw muscles? tooth grinding or clenching? Clicking, locking in jaw joints?*YesNoDon't knowPlease specify*Who suggested that you might need orthodontic treatment?*Why did you select our office?* Diseases / AllergiesHave 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?*YesNoPlease list any medical problems you have that might have an effect on your treatment in our office*Enter NA if not applicableList all current medications, and any additional comments…*Enter NA if not applicableHas your child reached puberty (menstruation, voice change, hair growth)?*YesNoDon't knowHas your child had any recent rapid growth?*YesNoDon't knowIf 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 healthSignature of Patient or Legal Guardian*Date HIPAA PolicyPrivacy 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 InformationI hereby authorize CC Braces to disclose facial and/or dental photographs, photographs, and video of the following patient as approved below:*YesNoMay the patient's picture be displayed on the reception computer screen for patient sign-in purposes?*YesNoMay 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?*YesNoMay 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?*YesNoMay the patient's records including photographs be used for the purposes of professional consultations, research, education or publication in professional journals?*YesNoPlease 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*DateDr. Colin Mihalik, DDS, MS5525 S. Staples Bldg. C Corpus Christi, Texas 78411