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Areas We Serve
Calabasas
West Hills
Woodland Hills
Winnetka
Canoga Park
Current Patients: 818-225-8800
New Patients: 747-318-5448
CHILD PATIENT FORM
Save up to 30 minutes at your first visit by completing your child’s Patient Registration and Evaluation forms from the convenience of your own home.
NEW PATIENT FORM
Step
1
of
6
- Personal Information
16%
Personal Information
Patient Full Name
*
First
Middle
Last
Grade
Date of Birth
*
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Name of School
Gender
Male
Female
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent's Names
*
Mother's Name
Father's Name
Mother's Employer
Father's Employer
Mother's Occupation
Social Security Number
Father's Occupation
Social Security Number
Siblings
Patient Lives With
Mother
Father
Both Parents
Billing Name
Relationship with Patient
Billing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Who may we thank for referring you?
Medical History
Physician’s Full Name
Physician’s First Name
Physician’s Last Name
Medical ID Number
Physician’s Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please answer the following questions:
Has patient undergone a physical exam in the past year?
Yes
No
Is patient presently under a physician’s care?
Yes
No
Has patient ever had a major surgery?
Yes
No
Has patient ever been hospitalized?
Yes
No
Is patient taking any pills, medications or drugs?
Yes
No
Is patient allergic to novocain or penicillin?
Yes
No
Has patient had any unusual reaction to any medication?
Yes
No
Has patient had tonsils and/or adenoids removed?
Yes
No
Does patient have fainting or dizzy spells?
Yes
No
Does patient have too high or too low blood pressure?
Yes
No
Is patient HIV Positive?
Yes
No
Have you ever been diagnosed or treated for the following?
Heart Problems
Yes
No
Heart Murmur
Yes
No
Kidney Problems
Yes
No
Lung Problems
Yes
No
Liver Problems
Yes
No
Allergies
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Hepatitis
Yes
No
Rheumatic Fever
Yes
No
Emotional Problems
Yes
No
Malignancies
Yes
No
Endocrine Problems
Yes
No
Bone Problems
Yes
No
Prolonged Bleeding
Yes
No
Tuberculosis
Yes
No
Asthma
Yes
No
AIDS or ARC
Yes
No
Are there any other medical problems we should be aware of?
Yes
No
If Yes, Please Explain
Dental History
Dentist's Full Name
Dentist’s First Name
Dentist’s Last Name
Dentist’s Phone
Date of Last Cleaning
Month
1
2
3
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7
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10
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12
Day
1
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31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
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1968
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1966
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1962
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1955
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1953
1952
1951
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1949
1948
1947
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1943
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1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Any Pending Work?
Dentist’s Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What is the major concern about the patient’s teeth?
Please answer the following questions:
Has patient ever had previous orthodontic consultation or treatment?
Yes
No
Has patient been informed of any extra or missing teeth?
Yes
No
Have any permanent teeth been removed by extraction?
Yes
No
Has any family member had orthodontic treatment?
Yes
No
If so who?
Does patient now suck his/her thumb or finger?
Yes
No
Does patient breath predominantly through the mouth?
Yes
No
Does patient have any speech problems?
Yes
No
Does patient grind or clench his/her teeth?
Yes
No
Does patient have pain or clicking of the jaw joint?
Yes
No
Have any teeth been injured or chipped due to an accident?
Yes
No
Has patient ever had pain in the face or head?
Yes
No
Has patient ever had severe jaw or head injury?
Yes
No
Do patient’s gums bleed on brushing or flossing?
Yes
No
Is patient concerned about the appearance of his/her teeth?
Yes
No
Does patient want his/her teeth straightened?
Yes
No
Are there any other dental/orthodontic problems we should be aware of?
Insurance Information
Parent/Guardian Initials
Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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11
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14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Insured's Name
Insured's SSN or IDN
Insured's Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
Yes
No
If yes, benefit amount:
If you have secondary insurance
Insured's Full Name
Insured's First Name
Insured's Middle Name
Insured's Last Name
Insured's Employer
Social Security Number
Insurance Company
Insurance Phone Number
Insurance Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
Yes
No
If yes, benefit amount:
Emergency Information
Name of nearest relative not living with you
Relative's First Name
Relative's Middle Name
Relative's Last Name
Relative's Phone Number
Relative's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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Home
About Us
Meet our Doctor
Meet Our Staff
Office Tour
Blog
Services
Pediatric Dentistry
Orthodontics for Children
Orthodontics for Adults
Sedation Dentistry
Emergency Dental Care
Dental Treatment for Special Needs
Laser Dentistry
Patient Resources
Child’s First Visit
Insurance & Financing
Patient Forms
FAQS
Contact Us
Areas We Serve
Calabasas
West Hills
Woodland Hills
Winnetka
Canoga Park
Current Patients: 818-225-8800
New Patients: 747-318-5448
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