Orthofi
Patient Login
Rockford Office
Call (616) 951-3006
Grand Rapids Office
Call (616) 656-4155
Request Your
Free Consultation
Why Us?
Clear Aligners
Invisalign
How Invisalign Works
Invisalign for Teens
Invisalign for Adults
Spark Clear Aligners
Spark Clear Aligners Case Study
Braces
Braces for Adults
Braces for Teens
Other Treatments
Gummy Smile (Gingivectomy)
Retainers for a Lifetime
New Patients
Blog
Contact Us
Orthofi Patient Login
Menu
Why Us?
Clear Aligners
Invisalign
How Invisalign Works
Invisalign for Teens
Invisalign for Adults
Spark Clear Aligners
Spark Clear Aligners Case Study
Braces
Braces for Adults
Braces for Teens
Other Treatments
Gummy Smile (Gingivectomy)
Retainers for a Lifetime
New Patients
Blog
Contact Us
Orthofi Patient Login
Orthodontist · Rockford & Grand Rapids, MI
Child/Teen Patient Registration
Home
»
Child / Teen Patient Registration
Step
1
of
7
14%
Patient Information
Patient Name
*
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Social Security Number
Age
Home Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zipcode
Email Address
*
Primary Phone Number
Phone Type
Home
Cell
Other
School
Grade
List any sports or extracurricular activities
Siblings (names and ages)
Parent/Guardian Information
Marital Status
*
Single
Married
Divorced
Widowed
Significant Other
Relation to Child
--- Choose Relation --
Mother
Father
Parent / Guardian's Name
Social Security Number
Driver's License Number
Date of Birth
MM slash DD slash YYYY
Is your address the same as the child's?
*
Yes
No
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zipcode
Primary Phone Number
Phone Type
Home
Cell
Other
Secondary Phone Number
Phone Type
Home
Cell
Other
Employer
Occupation
Emergency Contact Information
Emergency Contact Name (other than parents)
Relation to Child
Phone Number
Phone Type
Home
Cell
Other
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zipcode
Please add the name(s) of the person(s) we are authorized to release appointment and medically-related information to:
Authorized Person's Name
Relation to Child
Would you like to add an additional authorized person?
Yes
No
Authorized Person's Name
Relation to Child
Insurance Information
Do you have insurance?
*
Yes
No
Primary Insurance Information
Primary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Child
Policy Holder's Social Security Number
Policy Holder's Birthdate
Employer
Work Phone Number
Copay (if known)
Deductible (if known)
Do you have secondary insurance?
Yes
No
Secondary Insurance Information
Secondary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Child
Policy Holder's Social Security Number
Policy Holder's Birthdate
Employer
Work Phone Number
Copay (if known)
Deductible (if known)
Dental History
General Dentist Name
Date of Last Visit
Has your child visited an orthodontist before?
Yes
No
When?
For what reason?
What are your main orthodontic concerns?
How did you hear about our practice?
Ad
Internet
Family / Friend
Physician
Other
Name of person referring (if applicable)
Has your child's tonsils or adenoids been removed?
Yes
No
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Does your child have any missing or extra permanent teeth?
Yes
No
Has your child ever had an injury to (select all that apply):
Teeth
Mouth
Chin
Do your child's gums bleed?
Yes
No
Does your child have speech problems?
Yes
No
Tell us about your speech problem
Do your child currently or have they ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/Finger Sucking
Chewing/Eating Problems
Medical History
Is your child currently being treated by a physician?
Yes
No
Reason
Physician's Name
Date of Last Visit
Physician's Phone Number
Does your child have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list all allergies
Is your child currently taking any prescription or over-the-counter medications?
Yes
No
If yes, please list with dosages
Has your child ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Has your child had any serious illnesses or operations?
Yes
No
If yes, please describe
Has your child ever had a blood transfusion?
Yes
No
If yes, please list approximate dates
Has puberty and/or menstruation begun?
Yes
No
Is your child pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Check if your child has or have ever had any of the following:
Abnormal Bleeding
Anemia
Arthritis/Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Blood Transfusion
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Defect
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Difficulty Breathing
Drug/Alcohol/Abuse
Epilepsy
Emphysema
Fainting
Fever Blisters/Herpes
Glaucoma
Headaches
Heart Attack
Heart Surgery
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
High/Low Blood Sugar
HIV/AIDS
Hospitalized for Any Reason
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shingles
Shortness of Breath
Sickle Cell Disease/Traits
Sinus Problems
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Authorization
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 reponsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party
*
Today's Date
*
MM slash DD slash YYYY
CAPTCHA
Customize Your New Patient Experience
Schedule Your Free Virtual OR In-Office Consultation Today
Virtual Consultation
In-Office Consultation
We're Here When You Need Us
Our phone lines are open 7 days a week
Grand Rapids Office
616-656-4155 -
Rockford Office
616-951-3006
