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ADAMS ORTHODONTICS Child/Adolescent Orthodontic Acquaintance Form Patients name Nick name Date of birth Age years months Sex M F Address: Street City State Zip Telephone: () Daytime () School & Grade
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How to fill out childadolescent orthodontic acquaintance bform
How to fill out the child/adolescent orthodontic acquaintance bform:
01
Start by providing personal information such as the child's name, date of birth, and contact information.
02
Indicate the name of the primary dentist or orthodontist who referred the child for orthodontic treatment.
03
Fill in any relevant medical history, including allergies, chronic conditions, and medications.
04
Answer questions about the child's oral hygiene habits and any previous orthodontic treatment they may have had.
05
If the child has any orthodontic concerns or specific dental issues, describe them in detail.
06
Mention any pain or discomfort the child may be experiencing in relation to their teeth or jaw.
07
Include any additional information or concerns you would like the orthodontist to be aware of.
08
Sign and date the form to acknowledge that the provided information is accurate to the best of your knowledge.
Who needs child/adolescent orthodontic acquaintance bform:
01
Children or adolescents who have been referred to an orthodontist for evaluation or treatment.
02
Parents or legal guardians of the child/adolescent seeking orthodontic care.
03
Dental professionals, including dentists and orthodontists, who require background information on a child's dental history and concerns before initiating orthodontic treatment.
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