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Los Angeles: 11620 Wilshire Blvd. Suite 440, Los Angeles, CA 90025
|
Woodland Hills: 5350 Topanga Canyon Blvd, Woodland Hills, CA 91364

HOME
ABOUT US
TREATMENTS
NEW PATIENTS
BLOG
CONTACTS

Current Patients: (310) 444 1113
New Patients: (818) 495-9878

CHILD PATIENT FORM

Save up to 30 minutes at your first visit by completing your child’s Patient Registration and Evaluation forms from the convenience of your own home.

NEW PATIENT FORM

Step 1 of 6 - Personal Information

16%

Personal Information
Patient Full Name*
First Middle Last
Grade
Date of Birth*
Name of School
Gender
- Male
- Female
Home Address
Street Address Address Line 2 City State ZIP Code
Parent's Names*
Mother's Name Father's Name
Mother's Employer
Father's Employer
Mother's Occupation
Social Security Number
Father's Occupation
Social Security Number
Siblings
Patient Lives With
- Mother
- Father
- Both Parents
Billing Name
Relationship with Patient
Billing Address
Street Address Address Line 2 City State ZIP Code
Who may we thank for referring you?

Medical History
Physician’s Full Name
Physician’s First Name Physician’s Last Name
Medical ID Number
Physician’s Address
Street Address Address Line 2 City State ZIP Code
Please answer the following questions:
Has patient undergone a physical exam in the past year?
- Yes
- No
Is patient presently under a physician’s care?
- Yes
- No
Has patient ever had a major surgery?
- Yes
- No
Has patient ever been hospitalized?
- Yes
- No
Is patient taking any pills, medications or drugs?
- Yes
- No
Is patient allergic to novocain or penicillin?
- Yes
- No
Has patient had any unusual reaction to any medication?
- Yes
- No
Has patient had tonsils and/or adenoids removed?
- Yes
- No
Does patient have fainting or dizzy spells?
- Yes
- No
Does patient have too high or too low blood pressure?
- Yes
- No
Is patient HIV Positive?
- Yes
- No
Have you ever been diagnosed or treated for the following?
Heart Problems
- Yes
- No
Heart Murmur
- Yes
- No
Kidney Problems
- Yes
- No
Lung Problems
- Yes
- No
Liver Problems
- Yes
- No
Allergies
- Yes
- No
Diabetes
- Yes
- No
Epilepsy
- Yes
- No
Anemia
- Yes
- No
Arthritis
- Yes
- No
Hepatitis
- Yes
- No
Rheumatic Fever
- Yes
- No
Emotional Problems
- Yes
- No
Malignancies
- Yes
- No
Endocrine Problems
- Yes
- No
Bone Problems
- Yes
- No
Prolonged Bleeding
- Yes
- No
Tuberculosis
- Yes
- No
Asthma
- Yes
- No
AIDS or ARC
- Yes
- No
Are there any other medical problems we should be aware of?
- Yes
- No
If Yes, Please Explain

Dental History
Dentist's Full Name
Dentist’s First Name Dentist’s Last Name
Dentist’s Phone
Date of Last Cleaning
Any Pending Work?
Dentist’s Address
Street Address Address Line 2 City State ZIP Code
What is the major concern about the patient’s teeth?
Please answer the following questions:
Has patient ever had previous orthodontic consultation or treatment?
- Yes
- No
Has patient been informed of any extra or missing teeth?
- Yes
- No
Have any permanent teeth been removed by extraction?
- Yes
- No
Has any family member had orthodontic treatment?
- Yes
- No
If so who?
Does patient now suck his/her thumb or finger?
- Yes
- No
Does patient breath predominantly through the mouth?
- Yes
- No
Does patient have any speech problems?
- Yes
- No
Does patient grind or clench his/her teeth?
- Yes
- No
Does patient have pain or clicking of the jaw joint?
- Yes
- No
Have any teeth been injured or chipped due to an accident?
- Yes
- No
Has patient ever had pain in the face or head?
- Yes
- No
Has patient ever had severe jaw or head injury?
- Yes
- No
Do patient’s gums bleed on brushing or flossing?
- Yes
- No
Is patient concerned about the appearance of his/her teeth?
- Yes
- No
Does patient want his/her teeth straightened?
- Yes
- No
Are there any other dental/orthodontic problems we should be aware of?

Insurance Information
Parent/Guardian Initials
Date
Insured's Name
Insured's SSN or IDN
Insured's Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
- Yes
- No
If yes, benefit amount:
If you have secondary insurance
Insured's Full Name
Insured's First Name Insured's Middle Name Insured's Last Name
Insured's Employer
Social Security Number
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP 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
Relative's First Name Relative's Middle Name Relative's Last Name
Relative's Phone Number
Relative's Address
Street Address Address Line 2 City State ZIP Code

CAPTCHA
Notice of Privacy Practices*
- I acknowledge that I have read the Notice of the Privacy Practices of Atoosa Nikaeen Orthodontics

MAKE AN APPOINTMENT

Save time by filling out the above child patient form, then call us at (310) 444-1113 or send us an email to schedule a free initial consultation for patients in Los Angeles, Beverly Hills, and Santa Monica.

Current Patient: (310) 444-1113
New Patients: (818) 495-9878
info@invisibraces.com
11620 Wilshire Blvd. Suite 440,
Los Angeles, CA 90025

CONDITIONS

Orthodontic Disorders
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