New Patient Form Under 18

New Patient Form - Child - Under 18

* Required Fields

Patient Information

* Gender:
* Phone Type
* OK to leave message?

Parent / Guardian Information

Parent 1

* Marital Status
Relation to Child:
Phone Type:
Phone Type:

Parent 2

* Marital Status
* Relation to Child::
* Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
* Has your child visited an orthodontist before?
* Have we treated any other family members?
* Have your child's tonsils or adenoids been removed?
* Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
* Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
* Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

* Is your child currently being treated by a physician?
* Do you have any allergies/sensitivities to medications or latex?
* Is your child currently taking any prescription or over-the-counter medications?
* Has puberty and/or menstruation begun?
* Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

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.

I hereby authorize the release of any information pertaining to my child's 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.



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Lefort Orthodontics

  • Lefort Orthodontics - 2628 Country Club Rd., Lake Charles, LA 70605 Phone: 337-436-3631 Fax: 337-436-3632
  • Lefort Orthodontics - 420 Cypress Street, Sulphur, LA 70663 Phone: 337-528-2215

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