CRANFORD ORTHODONTIST ACCESSIBILITY STATEMENT

Cranford Orthodontist is committed to facilitating the accessibility and usability of its website, www.cranfordbraces.com, for everyone. Cranford Orthodontist aims to comply with all applicable standards, including the World Wide Web Consortium’s Web Content Accessibility Guidelines 2.0 up to Level AA (WCAG 2.0 AA). Cranford Orthodontist is proud of the efforts that we have completed and that are in-progress to ensure that our website is accessible to everyone.

If you experience any difficulty in accessing any part of this website, please feel free to call us at (770) 251-4444 or email us at info@cranfordbraces.com and we will work with you to provide the information or service you seek through an alternate communication method that is accessible for you consistent with applicable law (for example, through telephone support).

Child Patient Health History Form

All sections must be complete prior to submitting.

Patient Information
Phone Type?

Names and Ages of Children in Family

Responsible Party Information
Responsible Party Information (Secondary)
Party to be included in patient’s chart for scheduling and appointment matters.

Emergency Information

Dental Insurance
Primary Insurance (if insured's address is different than responsible party, please inform our office)
Do you have Insurance coverage for dentistry?
Do you have Insurance coverage for orthodontic treatment?
Secondary Insurance (if insured's address is different than responsible party, please inform our office)
Do you have Insurance coverage for dentistry?
Do you have Insurance coverage for orthodontic treatment?

Fee Expectations
If treatment is recommended for your child, what is your ideal DOWN payment?
If treatment is recommended for your child, what is your ideal MONTHLY payment?
If treatment is recommended for your child, what is your desired time frame to begin this exciting journey?

Health Questionnaire

General Information
NOW OR IN THE PAST HAS THE PATIENT HAD:
Diabetes
Tuberculosis
Endocrine or Thyroid
Asthma
Anemia
Prolonged Bleeding
Cancer
Epilepsy/Seizure
Hay Fever
Gastrointestinal Disorders
Herpes
Handicap/Disability
Radiation/Chemotherapy
Sickle Cell
Hearing Impairment
Mitral Valve Prolapse
Stroke
Sinus Problems
Ulcers
Drug Problems
Liver Involvement
Rheumatic Fever
HIV/AIDS
Fainting or Dizziness
Bone Disorders
Hepatitis
Nervous Disorders
Sleep Apnea
Heart Defect, Murmur
Kidney Involvement
Birth/Hereditary Problems
Immune System Problems
History of Eating Disorders
Arthritis or Joint Problems
Depression/Mental Health
High Blood Pressure
Low Blood Pressure
Heart disease, Heart attack
Skin Disorder

Allergies
Does the patient have allergies to the following
Latex
Erythromycin
Penicillin
Codeine
Nickel or other metals
Tetracycline
Dental Anesthetics
Aspirin
Acrylics

Airway and Sleep Questionnaire
While sleeping, does your child...
have trouble breathing or struggle to breath?
stop breathing during the night?
have "heavy" or loud breathing?
snore regularly?
Upon awakening, does your child...
have a problem with sleepiness during the day?
Additionally...
does your child have tired eyes/dark circles under the eyes?
does your child have seasonal allergies?
does your child have trouble breathing through the nose?
has your child been diagnosed with ADD, ADHD or another learning disability?
Dental History

To the best of my knowledge, the health information is complete and correct. I will not hold Cranford Orthodontics responsible for any errors or omissions that I have made in completing this form. I will notify Cranford Orthodontics of any changes in my medical or dental health. I understand that where appropriate, credit bureau reports may be obtained. I have also received a copy and read the notice of privacy practices.

 

Thank you for completing the above information. Please only click the “Submit” button once, as it may take a few moments to process. Once successfully submitted, you will be redirected back to the previous page and a confirmation message will appear.

 

 

Top