Online Child Patient Information Form

This is the online Child New Patient Information Form. If you are filling out this form for yourself, please visit this link to access the Adult Patient Information Form.

Please note that all of your responses will be encrypted and password-protected when you submit the form. Your responses are confidential and will never be stored on our website.
Child Patient Information Form

CHILD PATIENT INFORMATION

Name 

Nickname 

Sex: Female  Male 

Age 

Birthdate 

Street Address 

City 

State 

Zip Code 

Email 

Phone 

Name & Age of Siblings 

If the patient is a college student, please provide a residence address: 

Whom may we thank you referring you to our office? 

 

PARENT'S/GUARDIAN'S INFORMATION

Father's/Guardian's Name 

Address 

City 

State 

Zip Code 

Home Phone 

Work Phone 

Cell Phone 

Mother's/Guardian's Name 

Address 

City 

State 

Zip Code 

Home Phone 

Work Phone 

Cell Phone 

Email Address 

 

RESPONSIBLE PARTY INFORMATION

Person responsible for account 

Billing address 

City 

State 

Zip Code 

Relationship to patient 

 

EMERGENCY CONTACT

Name 

Relationship 

Address 

City 

State 

Zip Code 

Home Phone 

Work Phone 

Cell Phone 

 

The office of Dr. Brady will be happy to process your orthodontic claims.

To successfully process your claims, all of the following information is necessary.

If you do not have all of the required information we suggest you contact your Human Resources Representative and they can help you with any missing information.

 

DENTAL INSURANCE INFORMATION

Primary Insured's Name 

Insured's Date of Birth 

Insured's SSN 

Insured's Phone Number 

Insurance Company 

Insurance Co. Full Address 

Insured's Employer 

Group No. 

 

DUAL INSURANCE INFORMATION (if applicable)

Secondary Insured's Name 

Insured's Date of Birth 

Insured's SSN 

Insured's Phone Number 

Insurance Company 

Insurance Co. Full Address 

Insured's Employer 

Group No. 

 

 

MEDICAL HISTORY

Physician 

Phone 

Physician's Address 

City 

State

Zip Code 

General Health and Known Illnesses 

Present Medications 

Surgeries (with approximate dates)

Is there a possibility that the patient may be pregnant? Yes  No 

Has the patient ever had an allergic reaction to medication? Yes  No 

If Yes, please list the medication(s) 

Has the patient ever had an allergic reaction to foods; latex; any metals, especially Nickel or Titanium, or any other substance? Yes  No 

If Yes, please list the allergy(ies) to any of the above mentioned 

Has the paitent ever had any of the following:

Bleeding History: Yes  No 

Cancer: Yes  No 

Diabetes: Yes  No 

Hearing Loss: Yes  No 

Epilepsy: Yes  No 

Liver Problems: Yes  No 

High Blood Pressure: Yes  No 

Migraine Headaches: Yes  No 

Stomach Ulcers: Yes  No 

Hepatitis: Yes  No 

Kidney Problems: Yes  No 

AIDS or other immune system disorder: Yes  No 

Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion arteriosclerosis, stroke): Yes  No 

Damaged heart valves (Mitral valve prolapse, artificial heart valve, heart murmur) or any other conditions which may require the patient to be premedicated: Yes  No 

If yes to any of the above, does the condition require the patient to be premedicated? 

 

DENTAL HISTORY

Patient's Dentist 

Date of Last Visit (approx.) 

Dentist's Address 

City 

State 

Zip Code 

Have you previously consulted an orthodontist? Yes  No 

If yes, when and with whom? 

Have you consulted any other dental specialty? Yes  No 

If yes, when and with whom? 

Is there a history of congenitally missing teeth? Yes  No 

Patient  Relative(s) 

Do the patient's gums bleed when they brush their teeth? Yes  No 

Is any part of the patient's mouth sensitive to temperature? Yes  No 

Is any part of the patient's mouth sensitive to pressure? Yes  No 

Has the patient ever sucked their thumb or finger(s)? Yes  No 

If so, has the patient stopped this habit? Yes  No 

Does the patient breathe predominantly through their mouth? Yes  No 

Has the patient had their tonsils/adenoids removed? Yes  No 

If Yes, when? 

Does the patient clench or grind their teeth during the day? Yes  No 

Have you been made aware of the patient clenching or grinding their teeth during the night? Yes  No 

Does the patient now have, or has the patient ever had, pain in the jaw joint or the sides of the face (in and about the ears)? Yes  No 

Has the patient ever had clicking or popping in their jaw joint? Yes  No 

If Yes, please explain. 

Has the patient ever experienced pain when opening wide? Yes  No 

Has the patient had injury to their jaw? Yes  No 

If Yes, please explain. 

Has the patient had any injury to their teeth? Yes  No 

If Yes, please explain. 

 

If you would like us to get to know your child better, please have them fill out this section of the form.

Welcome to Dr. Brady's orthodontic office! We're looking forward to meeting you. Help us get to know you better by answering the following:

My nickname is 

I go to school at 

I am  years old and I'm in the  grade.

Some of my hobbies/interests include: 

My favorite food is 

My favorite type of music or group is 

I love to:

My friends that come here are 

I think having braces would be 

If you have any pets, what are they? 

Is there anything special you would like us to know about you? 



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Brady Orthodontics

  • Brady Orthodontics - 80 W. Welsh Pool Rd., Suite 203, Exton, PA 19341 Phone: (610) 363-2200 Fax: (610) 594-9360