Child New Patient Registration Form

Welcome! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Today's Date:

TELL US ABOUT YOUR CHILD

Name:     Nickname:     Male   Female

Date of Birth:     Age:     Child's Social Security #:

Address:     Apt:     City:     State:     Zip:

Child's Home Phone:     School Phone:

School:

WHO IS ACCOMPANYING THE CHILD TODAY?

Name:     Relation:

Do you have legal custody of this child? Yes No

Whom may we thank for referring you?

Other family members seen by us:

Previous/Present Dentist:     Last visit date:

Parent's marital status: Married   Partnered   Divorced   Widowed   Separated   Single

PARENT'S INFORMATION

Mother -   Name:

Mother   Stepmother   Guardian     Birthdate:

Social Security #:     Driver's License #:     Home Phone:

Name of Employer:     Work Phone:

Father -   Name:

Father   Stepfather   Guardian     Birthdate:

Social Security #:     Driver's License #:     Home Phone:

Name of Employer:     Work Phone:

PERSON RESPONSIBLE FOR ACCOUNT

Name:     Relation:

Billing Address:

Home Phone:     Driver's License #:

Employer:     Work Phone:

Who is responsible for making appointments?

INSURANCE COVERAGE

  Primary

Insurance Co. Name:     Insurance Co. Address:

Insurance Co. Phone:     Group # (Plan,Local, or Policy#):

Policy Owner's Name:     Relation:

Policy Owner's Birth Date:     SS#:

Policy Owner's Employer:     Employer's Address:

Orthodontic Coverage? Yes No

  Secondary

Insurance Co. Name:     Insurance Co. Address:

Insurance Co. Phone:     Group # (Plan,Local, or Policy#):

Policy Owner's Name:     Relation:

Policy Owner's Birth Date:     SS#:

Policy Owner's Employer:     Employer's Address:

Orthodontic Coverage? Yes No