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Please fill out the form below and we will answer it as soon as possible. Information submitted from this form will be kept on file for future reference.

Download a PDF version of our Referral Form here. You can fax it into our office at 506-858-1397.

Requested Doctor:	Dr. McManaman      Dr. Porter      Dr. Clifford
ABOUT YOUR CHILD
*Child´s First Name:
*Child´s Last Name:
They prefer to be called:
*Child´s Date of Birth:
Child´s E-Mail:
RESPONSIBLE PARTY / CONTACT PERSON
*First Name:
*Last Name:
*Relationship to patient:	Mother      Father      Other
Other relative, please explain:
*Mailing Address:
*Home Phone:
Cell Phone:
Home E-Mail:
Do they have orthodontic insurance?	Yes      No      Not Sure
Name of Employer:
Business Phone:
Business E-mail:
*Preferred Form of Contact:	Home Phone      Home E-Mail      Business Phone      Business E-Mail      Cell Phone
FINANCIALLY RESPONSILBE PARTY (If Different From Above)
First Name:
Last Name:
Relationship to patient:	Mother      Father      Other
Other relative, please explain:
Mailing Address:
Home Phone:
Cell Phone:
Home E-Mail:
Do they have orthodontic insurance?	Yes      No      Not Sure
Name of Employer:
Business Phone:
Business E-mail:
ALTERNATE CONTACT PERSON/PARENT
First Name:
Last Name:
Relationship to patient:	Mother      Father      Other
Other relative, please explain:
If Different From Above:
Mailing Address:
Home Phone:
Cell Phone:
Home E-Mail:
Name of Employer:
Business Phone:
Business E-mail:
GENERAL INFORMATION
How did you hear about our office?
Who may we thank for referring you?
Child´s Dentist:
Child´s Physician:
MEDICAL HISTORY
Does your child have allergies?	Yes      No
If yes, please indicate what the allergy is:
Does your child have a heart condition requiring antibiotics before dental procedures?	Yes      No      not sure
If yes, please explain:
Has your child been hospitalized in the last year?	Yes      No
If yes, please explain:
Is your child currently taking medication?	Yes      No
If yes, please explain:
Does your child have any muscle or arthritis problems?	Yes      No
If yes, please explain:
Does your child suffer from snoring or sleep apnea?	Yes      No
If yes, please explain:
Does your child have any tonsil or adenoid problems?	Yes      No
If yes, please explain:
Please explain any other medical problems:
DENTAL / ORTHODONTIC HISTORY Are you aware of any of the following problems:
Thumb or finger habit	Yes      No
Mouth breathing	Yes      No
Speech problems	Yes      No
Tongue thrust	Yes      No
Has your child been evaluated for orthodontic treatment in the past?	Yes      No
If yes, by whom and when?
Has your child had orthodontic treatment in the past?	Yes      No
If yes, by whom and when?
Has your child had periodontal (gum) treatment?	Yes      No
If yes, by whom and when?
Has your child ever had any injuries to your teeth?	Yes      No
If yes, please explain?
Are you happy with your child´s smile?	Yes      No
If not, what would you change?
Are you happy with the profile of your child´s face and/or bite?	Yes      No
If not, what would you change?
JAW PAIN / TMJ HISTORY
Is your child currently wearing a biteplane or night guard?	Yes      No
Has your child ever worn a biteplane or night guard in the past?	Yes      No
Is your child or has your child ever experienced jaw pain?	Yes      No
If yes, please explain?
Has your child been treated for jaw pain or TMJ?	Yes      No
If yes, please explain?
Has your child ever received a blow/trauma to your jaw?	Yes      No
If yes, please explain the incident:
Has your child experienced any of the following issues:
Grind their teeth	Yes      No
Clench their teeth	Yes      No
Noise in the joint when opening/closing	Yes      No
Jaw locking open/closed	Yes      No
Ringing/fullness in the ears	Yes      No
Headaches	Yes      No
PERSONAL
What extra-curricular activities or hobbies does your child enjoy?
Does your child participate in sports? If so, which ones?
Is there anything else you would like to add?
Do you have any friends or family that are undergoing treatment or have had treatment at our office?     Yes    No
Family member´s name(s):
Friend´s name(s):
How was their overall experience? Excellent      Good      Fair      Not Sure

* Required field

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