11620 Wilshire Blvd. Suite 440, Los Angeles, CA 90025
(310) 444-1113
Atoosa Nikaeen, D.D.S website logo

Orthodontic Forms for Child Patients in Los Angeles, Santa Monica

Save up to 30 minutes at your first visit by completing our online Patient Registration and Health History forms from the convenience of your own home.

Personal Information

First Name Middle Name Last Name Date of Birth Grade Name of School

Male Female

Home AddressStreet City StateZip Code

Contact InfoHome Phone Number Cell Phone E-mail Address

Mother’s Name Father’s Name Mother’s Employer Father’s Employer Mother’s Occupation Social Security # Father’s Occupation Social Security # Siblings
Patient Lives With: Both Parents Mother Father Other
Billing Name Relationship to Patient Billing AddressStreet City State

 

Zip Code

Who may we thank for referring you?

Medical History

Physician’s First Name Physician’s Last Name Physician’s Phone Date of Last Visit Medical ID Number

Physician’s AddressStreet City State

 

Zip Code

Please answer the following questions:
yes
no
Has patient undergone a physical exam in the past year?
Is patient presently under a physician’s care?
Has patient ever had a major surgery?
Has patient ever been hospitalized?
Is patient taking any pills, medications or drugs?
Is patient allergic to novocain or penicillin?
Has patient had any unusual reaction to any medication?
Has patient had tonsils and/or adenoids removed?
Does patient have fainting or dizzy spells?
Does patient have too high or too low blood pressure?
Is patient HIV Positive?
Have you ever been diagnosed or treated for the following?
yes
no
yes
no
Heart Problems
Hepatitis
Heart Murmur
Rheumatic Fever
Kidney Problems
Emotional Problems
Lung Problems
Malignancies
Liver Problems
Endocrine Problems
Allergies
Bone Problems
Diabetes
Prolonged Bleeding
Epilepsy
Tuberculosis
Anemia
Asthma
Arthritis
AIDS or ARC
Are there any other medical problems I should be aware of?

IF YES, PLEASE EXPLAIN

Dental History
Dentist’s First Name Dentist’s Last Name
Dentist’s Phone Date of Last Cleaning
Any Pending Work?
Dentist’s Address
Street City StateZip Code

What is the major concern about the patient’s teeth?

Please answer the following questions:
yes
no
Has patient ever had previous orthodontic consultation or treatment?
Has patient been informed of any extra or missing teeth?
Have any permanent teeth been removed by extraction?
Has any family member had orthodontic treatment?
if so who?
Does patient now suck his/her thumb or finger?
Does patient breath predominantly through the mouth?
Does patient have any speech problems?
Does patient grind or clench his/her teeth?
Does patient have pain or clicking of the jaw joint?
Have any teeth been injured or chipped due to an accident?
Has patient ever had pain in the face or head?
Has patient ever had severe jaw or head injury?
Do patient’s gums bleed on brushing or flossing?
Is patient concerned about the appearance of his/her teeth?
Does patient want his/her teeth straightened?
Are there any other dental/orthodontic problems I should be aware of?

Parent/Guardian Initials Date

Insurance Information

Insured’s Name Insured’s SSN or IDN
Insured Employer Insurance Company
Insurance Phone Number
Insurance Address
Street
City
StateZip Code
Group Number
Local Number
Do you have orthodontic coverage? yes no
If yes, benefit amount:
If you have secondary insurance
Insured First Name Middle Name
Last Name Social Security #
Insured’s Employer Insurance Company
Insurance Phone Number
Insurance Address
Street City
StateZip Code
Group Number Local Number
Do you have orthodontic coverage? yes no
If yes, benefit amount:

Emergency Information
Name of nearest relative not living with you
First Name Middle Name
Last Name
Complete Address
Street City StateZip Code
Phone Number

Notice of Privacy Practices
Please take a moment to read our Notice of Privacy Practice
I, , acknowledge that I have received and read a Notice of the Privacy Practices of Atoosa Nikaeen Orthodontics.
Signature of Patient or Guardian:
Relationship to Patient if Guardian or Representative:
Enter the security code:CAPTCHA Image

 

Please call us at (310) 444-1113 or send an email to schedule your free initial consultation. We serve Southern California including Los Angeles (LA), Beverly Hills, and Santa Monica.

We look forward to hearing from you!