WILMINGTON ORTHODONTIC CENTER

Child new patient form

 

To assist us in providing the most complete service, please provide the following information and health history.

Your email adress *
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Name and surname *
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Preferred to be called *
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Gender *
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Age *
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Date of birth *
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School
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Grade
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Brothers/Sisters
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Ages *
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Dentist
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Physician
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Referred by
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Family members we have seen
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What is the reason for your visit?
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Mother:
Name and surname *
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Street Address *
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Address line 2 *
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City *
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State / Province / Region *
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Postal / Zip code *
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Country *
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Employed by *
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Work Phone Number *
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Cell Phone Number *
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Marital Status *
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Patient lives with *
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Father:
Name and surname *
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Street Address *
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Address line 2 *
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City *
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State / Province / Region *
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Postal / Zip code *
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Country *
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Employed by *
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Work Phone Number *
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Cell Phone Number *
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DENTAL HISTORY
Please check all that apply:

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Recent dental checkup *
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Date *
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Previous orthodontic treatment *
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Date *
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Please note any other factors the doctor should know about the patient's dental health:
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MEDICAL HISTORY
Please check all that apply:

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Allergies to medications. Please list if any:
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AUTHORIZATION
I authorize the relase of medical and dental information to insurance carriers and to other healthcare providers involved in the care of this patinet and the use of records by Dr. Pancko for teaching purposes and scientific publication. Please advise Dr. Pancko of any changes in your childs medical or dental health while under the care of our office. I hereby authorize Dr. Pancko to obtain credit reports if necessary.
Name *
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Date *
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SMILE GALLERY

Testimonials

With so many great choices in the area for a good orthodontist, we searched and searched for the best fit and are so glad we found Dr. Pancko. The doctor is so wonderful, instantly giving us the feeling that our son is in good medical hands with a qualified and knowledgeable orthodontist.

Dave Marcus