New Patient Form – Child

  • Patient Information

  • MM/DD/YYYY
  • Parent / Guardian Information

  • Emergency Contact Information

  • Insurance Information

  • Dental History

  • MM/DD/YYYY
  • Medical History

  • MM/DD/YYYY
  • For Female Patients Only

  • Terms of Agreement

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
  • By typing my name, I acknowledge I agree to the terms of agreement mentioned above.
  • Please enter the verification codes listed below to continue with submitting your form.