New Patient Form - Child

Welcome to Tri-Valley Orthodontics! Please complete the form below (along with the Child Medical & Dental History Form & HIPAA Form) and submit them prior to your complimentary consultation. If you prefer to fill out the form on paper please refer to our Forms link to print, scan and email them to us at info@tri-ortho.com. Submitting your forms prior to your visit will save a lot of time at your initial visit, so you can get right to getting your records done & meeting with Dr. Ko or Dr. Yoon. We’re looking forward to meeting you soon!

Today's Date

YYYY

Welcome! How did you hear about us?

Primary reason for consultation:

Is this your first orthodontic consultation?

Yes

Has the patient had any previous orthodontic treatment?

PATIENT'S INFORMATION

Patient's Name

First Name

Last Name

Primary Email (Important - All office correspondence & appointment reminders will be sent here)

Primary phone number (Important - All appointment reminders will be sent here via text)

(###)

###

####

Alternate phone number

(###)

###

####

Primary Mailing Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current School Name:

PATIENT'S GENERAL DENTIST INFORMATION

General Dentist's Name

First Name

Last Name

City in which your General Dentist is located

Date of last cleaning:

General Dentist Phone Number

(###)

###

####

PARENT INFORMATION

Father's Full Name

First Name

Last Name

Father's Email Address

Father's Phone Number

(###)

###

####

Father's Work Number

(###)

###

####

Mother's Full Name

First Name

Last Name

Mother's Email Address

Mother's Phone Number

(###)

###

####

Mother's Work Number

(###)

###

####

PRIMARY INSURANCE INFORMATION (If you have already provided your insurance information please skip to the bottom and submit your NP Form)

Please provide your dental insurance information (if applicable) prior to your consultation - nothing will be charged to your insurance before your consultation visit - your consultation is completely complimentary. As a service to you, we'll verify your orthodontic benefits for you and be able to provide you with an accurate estimate of treatment at your consultation visit.

Will your insurance policy by changing or terminating soon?

If so please contact our Insurance Coordinator at Frontdesk@tri-ortho.com, as this will change your expected benefits.

Policy Holder Name:

First Name

Last Name

Policy Holder's Date of Birth

Employer Name:

Insurance Company Name:

Insurance Phone Number:

(###)

###

####

Subscriber ID:

Group Number:

SECONDARY INSURANCE INFORMATION (If Applicable)

Policy Holder Name:

First Name

Last Name

Policy Holder's Date of Birth

00/00/0000

Employer Name:

Insurance Company Name:

Insurance Phone Number:

(###)

###

####

Subscriber ID:

Group Number:

New Patient Form - Child

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