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Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental

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We'd Like To Get To Know You!

We have created this short form to help us give you the best care possible! The answers you give will be kept strictly confidential, this is between you and your doctor.
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​​​​​​​New Patient and Health History Form

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Sex*

Is your child adopted*

Previous Dentist

Date of last visit*

Your child's attitude toward dental care

Who has legal guardianship of your child?*

How did you hear about our office*

Is your child engaged/use social media?


​​​​​​​Medical Information

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Is your child taking medication?

Has your child ever been hospitalized?*

Has your child had a history or difficulty with any of the following: (please check all that apply)*

Any other comments or details in regards to your child's medical information

Does your child have any emotional or school problems?

Allergies to Food or Medications*


​​​​​​​Dental Information

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Does your child brush regularly?*

How often?

Does your child floss?*

How often?

Has either parent or child been treated orthodontically?

How do you expect your child's reaction will be towards receiving dental care in our office?

Describe your child:


​​​​​​​Responsible Party Information

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First Name*

Last Name*

Address*

City, State, Zip*

Home Phone

Cell Phone*

Work Phone

Date of Birth (please use MM/DD/YYYY)*

Social Security Number

Employer

Email

Who can we thank for referring you to our practice?


​​​​​​​Mother's Information

(If different from responsible party
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Name

Employer

Occupation

Address

Cell Number

Date of Birth (please use MM/DD/YYYY)


​​​​​​​Father's Information

(If different from responsible party
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Name

Employer

Occupation

Address

Cell Number

Date of Birth (please use MM/DD/YYYY)


​​​​​​​Primary Dental Insurance


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Policy Holder's Name

Social Security Number

Policy Number

Insurance Company

Insurance Address

Insurance Phone

Does your child have secondary dental insurance?


Financial Policy

Your child’s estimated share of cost is due and payable on the day the treatment is performed. Understand that dental insurance usually covers only part of the fees for services based on your specific dental benefit underwriting. We do our best to provide you with an estimate accordingly. Please understand that the contract for dental insurance is between you and your insurance company and not our practice. Any disputes of coverage need to be handled through the insurance company directly by you and you accept personal financial responsibility for services provided. Your signature here authorizes assignment of benefits to us so we can submit claims. To avoid missed appointment charges we request that you inform us of cancellation notice 48 hours prior to the appointment, so that we can offer the appointment to another child. If you have 2 broken appointments, you will be automatically charged $50.00 for your missed appointments. A broken appointment is considered a “no show” or canceling an appointment the same day. The signature of the responsible party / Legal Guardian below authorizes Dr. J Shahangian or qualified assignee to complete an oral evaluation including but not limited to examination, cleaning, fluoride and/or diagnostic X-rays as indicated to evaluate oral health.
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Signature Box (to be signed in office)

Date (to be filled in office)