Child New Patient Information | ELD Orthodontics

* Patient Name: (Required)

Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number: Home Cell

Name of Mobile Phone Carrier

* E-mail: (Required)

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent/Guardian Information

Mother Step-Mother Guardian Other

Name:

Social Security Number:

Birth Date:

Driver License Number:

Address (if different than child's):

City:

State:

Zip:

Phone Number: Home Cell

Name of Mobile Phone Carrier

Secondary Phone Number: Home Cell

Name of Mobile Phone Carrier

Employer's Name:

Occupation:

Father StepFather Guardian Other

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's) :

City:

State:

Zip:

Phone Number: Home Cell

Name of Mobile Phone Carrier

Secondary Phone Number: Home Cell

Name of Mobile Phone Carrier

Employer's Name:

Occupation:

Emergency Contact Information

Insurance Information

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

Medical History

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

Submitted by:

Date: