top of page
Home
The Office
Our Doctors
The Staff
FAQ
Invisalign
Braces
More
Plans & Pricing
Patient Info
More
Use tab to navigate through the menu items.
PATIENT FORM - CHILD
Welcome to McCranels Orthodontics
CHILD INFORMATION
First name
Middle name
Last name
Date of Birth
Sex
Male
Female
Prefered Name
Hobbies/Interests
School
Grade
Home Address
City
Zip
Home Phone
Parents's Name(s)
Business Address
Mom Cell
Dad Cell
Work Phone
Occupation
FINANCIAL AND INSURANCE HISTORY
Names of Person Responsible for Account
Social Security No
Address (if different from patient)
Relationship to Patient
MaritalStatus
Married
Divorced
Separated
Single
Do you have dental insurance that covers orthodontic treatment?
Yes
No
Not Sure
Name of Insurance Company
Policy Holder Name
Date of Birth
I.D.#
Monthly payments preferred?
$200
$300
$400
$500
Payment in full discount
MEDICAL HISTORY
Family physician is
Last visit was
Is the patient under the care of a physician for a specific problem at this time?
Yes
No
If yes, why?
Submit
Thanks for submitting!
bottom of page
