Patient Information

CHILD'S INFORMATION

Child's First Name

Child's Last Name

Child's DOB

Child's Gender:

Parents Guardian Information

Mother's Information

Relationship

Mother

Guardian

Stepmother

First Name

Last Name

Mother's Birthdate

Mother's SSN

Street Address

Street Address Line 2

City

State

Zip

Mother's Employer

Mother's Driver's License #

Mother's Home Phone

Mother's Work Phone

Mother's Mobile Phone

Mother's Occupation

Father's Information

Relationship

Father

Guardian

Stepfather

First Name

Last Name

Father's Birthdate

Father's SSN

Same as above

Street Address

Street Address Line 2

City

State

Zip

Father's Employer

Father's Driver's License #

Father's Home Phone

Father's Work Phone

Father's Mobile Phone

Father's Occupation

Responsible Party's Information

First Name

Last Name

Relationship

Referred to our office by

INSURANCE INFORMATION

Check the box if you or your child don't have insurance

PRIMARY

Primary Insurance Co

Primary Ins. Phone #

Primary Ins. Co. Address

Primary Insured Name

Relationship

Primary Insured ID/Employee

Employer

Group #

Secondary

Secondary Insurance Co

Secondary Ins. Phone #

Secondary Ins. Co. Address

Secondary Insured Name

Relationship

Secondary Insured ID/Employee

Employer

Group #

It's our policy to discuss our fees and financial arrangement openly and honestly with you. Regardless of whether you have dental insurance or not, you are responsible for the full financial cost of dental treatment. Every effort will be made to estimate to the best of our ability the total cost of dental treatment. Please be aware that treatment rendered may vary from the estimated treatment plan due to the continual progression of dental decay with time. Payment is expected as dental services are performed unless financial arrangements have been previously made with our office.

E-mail Address

Signed By

Signature

Date

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