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Meet Our Team(s)!
Dr. Tonya Baker
The Team Of Baker Orthodontics
Dr. Kelle Cox
The Team of Grins and Giggles
Orthodontics
Invisalign Preffered
Ceramic Braces
Speed Treatment
Comfort Braces
Retainers
Embrace It Program
Pediatric Dentistry
Why Baker?
Free Check Ups
Invisalign Preffered
Guarantees
Family Discounts
Payment Options
Reward Program
Community Involvement
Q.A.
Dental Aquaintence Form
1. Tell Us About Your Child
Sex:
Male
Female
Date Of Birth:
2. Mother's Information
Step Mother
Guardian
Birthdate
Allow Text Alerts?
Yes
No
Single
Married
Seperated
Widowed
Divorced
3. Father's Information
Step Father
Guardian
Birthdate
Allow Text Alerts?
Yes
No
Single
Married
Seperated
Widowed
Divorced
4. Person Responsible For Account
5. People Authorized To Bring Child To Appointments
6. Primary Dental Insurance
Birthdate
7. Secondary Dental Insurance:
Birthdate
Medical And Dental History
Is the child currently under the care of a physician?
Yes
No
Please describe the child's current physical health:
Good
Fair
Poor
Are Immunization's Current?
Yes
No
Medical History
- Has your child ever been treated for:
ADD/ADHD
Yes
No
Anemia
Yes
No
Anxiety Disorder
Yes
No
Aids / HIV
Yes
No
Tuberculosis
Yes
No
Cancer
Yes
No
Eye Problems
Yes
No
Diabetes
Yes
No
Dizziness / fainting
Yes
No
ENT Disorder
Yes
No
Eating Disorder
Yes
No
Cerebral Palsy
Yes
No
Hearing / Speech
Yes
No
Kidney Problems
Yes
No
Hives
Yes
No
Liver Problems
Yes
No
Scarlet Fever
Yes
No
Handicaps / Disabilities
Yes
No
Head Injury
Yes
No
Heart Disease
Yes
No
Hepatitis Type
Yes
No
High Blood Pressure
Yes
No
Kidney / Bladder / UTI
Yes
No
Depression
Yes
No
Migraine Headaches
Yes
No
Menstrual Disorders
Yes
No
Mononucleosis
Yes
No
Hemophilia Type
Yes
No
Recent Weight Loss
Yes
No
Sickle Cell
Yes
No
Heart Murmur
Yes
No
Blood Transfusion
Yes
No
Cleft Palate
Yes
No
Rheumatic Fever
Yes
No
Autism
Yes
No
Dental History
- Has your child ever had problems with:
Gum Infection
Yes
No
Color of teeth
Yes
No
Thumb Sucking
Yes
No
Does he / she brush their own teeth
Yes
No
Does he / she floss their own teeth
Yes
No
Was he / she breast or bottle fed
Sensitive Teeth
Yes
No
Tooth Alignment
Yes
No
Cavities / Toothache
Yes
No
Does he / she use fluoride toothpaste
Yes
No
Does he / she go to bed with a bottle
Yes
No
Date Stopped:
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