Child Patient Registration

_2017 Child Registration Form – Ortho Custom

Patient Information

Please Tell Us About Your Child

Gender:

Child's Dentist

Responsible Party and Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Insurance

Orthodontic Coverage?

Dental History

Has your child ever been evaluated by an orthodontist or had orthodontic treatment?
Have you ever had severe injuries to the face, teeth, mout or chin?
Has your child's tonsils or adenoids been removed?
Has your child you have ever been informed of any missing or extra permanent teeth?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun (girls)?
Please describe your child's current general health:

Medical History

Has your child ever had any of the following medical problems:
Does your child currently or has your child ever had any of the following habits?

Notice of Privacy Practices

Click the link below to view the Notice of Privacy Practices.

Notice of Privacy Practices

Authorization

I understand that the information I have given above is correct to the best of my knowledge, that where appropriate credit bureau reports will be obtained, and that it will be held in strict confidence. It is my responsibility to inform Dr. Sadler of any changes in my medical and dental status. I hereby authorize release of information for any proposed treatment to my/our insurance company and for insurance payment of said treatment to be paid directly to Sadler Orthodontics. I further authorize release of orthodontic records to other healthcare providers involved in my dental/orthodontic care and the use of these records by Dr. Sadler for teaching purpose and or scientific publication.



Security Measure

Sadler Orthodontics

  • Fishers Office - 11921 Lakeside Dr., Fishers, IN 46038 Phone: (317) 594-0888
  • New Castle Office - 916 S. Main St., New Castle, IN 47362 Phone: (765) 521-4500
  • Richmond Office - 1923 Chester Blvd., Richmond, IN 47374 Phone: (765) 935-5251

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