Patient and Family Information

Child's Name
Birthdate
Home Address
City
State
Zip
School
Grade
Responsible Party
Relationship to Child
Name of Mother/Guardian
Birthdate
City
State
Zip
Employer
Business Phone
Cell Phone
Email
Name of Father/Guardian
Birthdate
City
State
Zip
Employer
Business Phone
Cell Phone
Email

Child's Dental History

Former Dentist
Office Phone
Address
City
State
Zip
Date of last dental visit
How often your child brush ?
How often your child floss ?
Please check all that apply to your child:

Child's Dental History

Please check all that apply to your child:

Primary Dental Insurance

Person Responsible for Account
Relationship to Patient
Birthdate
Address
City
State
Zip
Employer
Business Phone
Business Address
Occupation
Insurance Company
Insurance Company Address
Subscriber I.D.#
Group #

Additional Insurance

Person Responsible for Account
Relationship to Patient
Birthdate
Address
City
State
Zip
Employer
Business Phone
Business Address
Occupation
Insurance Company
Insurance Company Address
Subscriber I.D.#
Group #

Assignment and Release

I hereby authorize payment directly to

for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature of Responsible Party Date

Signature of Responsible Party
Date