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.
TELL US ABOUT YOUR CHILD
Date of Birth: Age:
Child's Social Security #:
Child's Home Phone:
WHO IS ACCOMPANYING THE CHILD TODAY?
Do you have legal custody of this child? Yes
Whom may we thank for referring you?
Other family members seen by us:
Previous/Present Dentist: Last visit date:
Parent's marital status:
Mother - Name:
Social Security #: Driver's License #:
Name of Employer: Work Phone:
Father - Name:
PERSON RESPONSIBLE FOR ACCOUNT
Driver's License #:
Employer: Work Phone:
Who is responsible for making appointments?
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Group # (Plan,Local, or Policy#):
Policy Owner's Name:
Policy Owner's Birth Date: SS#:
Policy Owner's Employer:
Orthodontic Coverage? Yes
Policy Owner's Birth Date: