Child Patient Registration | Gowasack Family Dentistry

Tell us about your child:

Today's Date: Child's Home Phone:

Social Security: Birth Date: Age:

Name: Nickname:

Male Female School: Grade:

Child's Address:

City: State: Zip:

Who is accompanying the child today?

Name: Relation:

Do you have legal custody of this child? Yes No Is the child adopted? Yes No

Is the child in a foster home? Yes No

Whom may we thank for referring you?

Neighbor or relative not living with you:

Name: Relation:

Home Phone: Work Phone:

Address:

Parent's Information:

Marital Status: Married Divorced Widowed Separated Remarried Single

Mother Stepmother Guardian

Name: Home Ph: Work Ph:

Birth Date: Social Sec.#: Driver's Lic.#:

Address:

Employer: Length of Employment:

Father Stepfather Guardian

Name: Home Ph: Work Ph:

Birth Date: Social Sec.#: Driver's Lic.#:

Address:

Employer: Length of Employment:

Person responsible for account:

Name: Relation:

Social Security: Drivers License:

Billing Address:

Home Ph: Work Ph: Employer:

Who is responsible for making appointments?

Insurance Coverage:

Primary Medical Coverage Dental Coverage Orthodontic Coverage

Insurance Company: Insurance Phone:

Insurance Address: Group#:

Policy Owner's Name:

Policy Owner's Employer:

Work Address:

Relation to patient:

Policy Owner's SS#:

Policy Owner's Birthdate: