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Child Registration Form

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Patient Information

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Home Address*

Parental Information

Who is with the child with today?*
Who is the legal guardian of the child?*
Mother's Name*
Address (if different from the patient'(s)
Father's Name*
Address (if different from the patient'(s)

Responsible Party Info

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Billing Address*
Emergency Contact*

Dental Insurance

Insurance Address
Do you have secondary coverage?
Insured Name
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Dental History

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Dentist Address*
Has child complained about dental problems?*
Does child brush teeth twice a day?*
Does your child floss every day?*
Is fluoride taken in any form?*
Any injuries to mouth, teeth, head?*
Any unhappy dental experiences?*
Any mouth habits - thumbsucking, nail biting, mouth breathing, grinding, clenching, etc.?*
Has the child ever had any pain in the jaw joint (TMJ/TMD)?*
Child's dental health*
Child's physician
Physician's address

Medical History

Is the child currently under the care of a physician?*
Receiving any medications or drugs?*
Ever been hospitalized?*
Ever had surgery?*
Is there excessive bleeding when cut?*
Does the child have any history of or difficulty with any of the following? If yes, please check.*


To the best of my knowledge, the above is complete and correct. I understand that it is my responsibility to inform my doctor if there are any changes in my health.
Enter the name of your child.
Enter the name of your insurer.
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"I highly recommend anyone needing orthodontics - young or old- to check out Dr. Montini. He is professional, friendly, and all about his patients having a good experience. Their facility is beautiful and very kid & adult-friendly!"

— Deb H.

"We could not be more pleased with the work that was done by Dr. Montini on my daughter's teeth. I HIGHLY recommend anyone looking for an orthodontist to look no further than Dr. Montini. He and his staff are wonderful."

— Ardis B.

"Dr. Montini and his staff are simply the best! Look no further if you are searching for a wonderful orthodontist. I couldn't be happier with how my kids are treated and how great the results have been."

— Angela B.

"Absolutely amazing, professional, and fast service. I love how passionate everyone is about helping out the people they see."

— Bobby T.

"Dr. Reid Montini has built a practice that actually makes orthodontist visits 'fun'. From superhero drawings and a video game room, your kids will actually enjoy a doctor's visit. All fun aside, Dr. Montini has true passion in making your entire family's smiles picture perfect. It is a change that will last a lifetime."

— John M.

"Dr. Montini is a warm, personable, highly trained and skilled orthodontist. I have seen truly phenomenal changes he has made in restoring proper bite in even the most difficult of cases. He not only restores the smile nature intended, but improves eating (chewing) and thus digestion, nutritional uptake, and overall health. Dr. Montini is great with kids, too!"

— Amy G.

Dream. Live. Smile.

Dream the possibilities.

Live every moment.

Smile with confidence.

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7520 W University Ave
Suite C
Gainesville, FL 32607
(352) 332-7911


3201 SW 34th Ave #202, Ocala, FL 34474
(352) 237-3366