Child Berkeley & Orinda Orthodontics Patient Registration
Welcome to Berkeley Orthodontics! Please fill out this patient information form for our data. Your information is secure and confidential, and a copy of your responses will be sent to the parent's email once you have completed this form.
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Patient Information
Today's Date *
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Patient's Name *
Patient's Address *
Street, City, State, Zip Code
Parent's Email *
Parent's Preferred Phone Number *
Parent's Home Phone Number *
Patient's Gender *
Pronouns *
Patient's Birthday *
MM
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Patient's School *
Dentist Name *
Who may we thank for referring you? *
If "Denist, Family, Friend, or Other" was chosen in previous question, please specifiy:
Parent/Guardian Information
Are the parents: *
If the parents are separated or divorced, who has primary responsibility?
If the parents are separated or divorced, who should receive information about patient treatment?
1. Parent's Title
Clear selection
Parent's Name *
First and last name
Work Phone
Cell Phone *
Home Phone *
Preferred Phone *
Parent's Address (if different from patient)
Street, City, State Zip Code
Parent's Email *
Parent's Employer
Parent's Employer City
2. Parent's Title
Clear selection
Parent's Name
Work Phone
Cell Phone
Home Phone
Preferred Phone
Clear selection
Parent's Address (if different from patient)
Street, City, State, Zip Code
Parent's Email
Parent's Employer
Employer's City
If applicable, please list any additional parent information
1. Name
Primary Phone Number
Email Address
2. Name
Primary Phone Number
Email Address
Emergency Contacts
1. Name *
Relationship to Patient *
Phone Number *
2. Name
Relationship to Patient
Phone Number
Patient's Siblings
If the patient has any siblings, please fill out the portion below. If not, you may continue to the insurance portion.
1. Name
School
Age
2. Name
School
Age
Patient Insurance Information
A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patient’s account and the patient or person responsible for the account is responsible for payment of all fees incurred. We will gladly assist you in submitting insurance claims pertaining to any charge for care in our office.
Is patient covered by dental insurance? *
Is your insurance an ACA (Affordable Care Act) plan?
Clear selection
Subscriber Name
Relationship to Patient
Name of Employer
Contact #
Subscriber Social Security Number
Delta/CA or Delta/State
Clear selection
Subscriber Birthday
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Insurance Company
Group #
Subscriber #
Employer Phone
Additional Insurance
If you have any additional insurance, please indicate it here.  If not, continue to the next session.
1. Name of Policy Holder
Policy Holder's Birthday
MM
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Policy Holder's Social Security Number
Insurance Company
Group #
Contact #
2. Name of Policy Holder
Policy Holder's Birthday
MM
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DD
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YYYY
Policy Holder's Social Security Number
Insurance Company
Group #
Contact #
Dental History and Status
When was the patient last seen by a dentist? *
1. Is the patient taking any pills or medications for dental reasons? *
If yes, which ones?
2. Have there been any unusual reactions to dental medications? *
If yes, please specify.
3. Has the patient had trouble associated with dental treatment? *
If yes, please specify.
4. Has the patient seen a periodontist, endodontist, or oral surgeon?
Clear selection
If yes, for what reason?
5. Has the patient had previous orthodontic treatment or consultation? *
If yes, who, when, and why?
6. Has any member of the patient's family had orthodontic treatment? *
If yes, for what reason?
7. Has the patient had any teeth extracted? *
If yes, for what reason?
8.  Has the patient ever injured or broken any teeth? *
If yes, how?
9. Has the patient ever been injured in the head or face? *
If yes, please specify.
10. Does the patient have any missing or extra teeth? *
If yes, please specify.
11. Does the patient have any problem with eating, chewing, or swallowing? *
If yes, please specify.
12. Does the patient have any dental or facial pain? *
If yes, please specify.
13. Does the patient's jaw joints make noise or hurt when opening, closing or chewing? *
If yes, please specify.
14. Does the patient habitually grind or clench teeth together? *
If yes, please specify.
15. Is the patient aware of any swellings or growths in the mouth or on your face? *
If yes, please specify.
16. Does the patient suck thumb, fingers, tongue, blanket, or pacifier? *
If yes, please specify.
17. Does the patient have any negative or resistant feelings about orthodontic treatment? *
If yes, please specify
18. Is the patient especially concerned about orthodontic treatment? *
If yes, please specify.
19. Is the patient dissatisfied with the appearance of their teeth? *
If yes, please specify
20. Is the patient specifically resistant to braces? *
If yes, please specify
21. Is the patient specifically resistant to headgear? *
If yes, please specify
22. Is there any other information we should know? *
If yes, please specify.
Medical History
Who is the patient's physician? *
Physician's Phone
When was the patient last seen by a physician? *
1. Has the patient seen an ENT specialist, endocrinologist, neurologist, allergist, hematologist, cardiologist, psychiatrist, or plastic surgeon?   *
If yes, which one(s)?
2.  Is there a current medical problem? *
If yes, please specify
3. Is the patient taking any pills, medications, or drugs? *
If yes, please specify
4. Has the patient had an unusual reaction to any medication? *
If yes, please specify
5. Is the patient receiving or ever received Biphosphonate treatment (e.g., Fosamax)? *
6. Does the patient have any known allergies? *
If yes, please specify
7. Has the patient had a serious illness? *
If yes, please specify
8. Has the patient had any surgery or been hospitalized? *
If yes, please specify
9. Are there any congenital (that the patient was born with) problems? *
If yes, please specify
Patient's Weight *
Patient's Height *
Medical History, continued
Has the patient ever been diagnosed with any of the following:
Diabetes *
Thyroid Problem *
Sickle cell anemia *
Heart trouble *
AIDS or HIV+ *
Emotional Problems *
Prolonged bleeding *
Bone disease *
Multiple sclerosis *
Anemia *
Jaundice *
Cancer *
Breathing trouble *
Rheumatic Fever *
Cerebral Palsy *
Arthritis *
Hepatitis *
Stomach Ulcers *
Liver Problem *
Tonsillitis *
Fainting *
Epilepsy *
Tuberculosis *
Kidney problem *
Asthma *
Low Blood Pressure *
Medical History, continued
What is the reason for your visit today? *
If there are there any other family members who have had treatment at Berkeley/Orinda Orthodontics, please specify who and for what reason:
Confirmation and Electronic Signature
I hereby certify that the above information is accurate to the best of my knowledge and allow Berkeley Orinda Orthodontics to use this information during my treatment. I understand that an incomplete or improperly completed form may prevent me from receiving proper treatment. *
Electronic Signature: *
Please type your full legal name below.
Today's Date: *
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CONFIDENTIALITY NOTICE

The personal health information and communication contained in this form is highly confidential and legally privileged.
It, along with any information, is solely for the use of the intended recipients(s).
Unauthorized interception, review, use or disclosure is prohibited and may violate applicable laws, including the Electronic Communications Privacy Act.
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