Child Patient Form

Child Patient Information

Person Responsible for Account

Dental Insurance Information

Primary Insurance

Secondary Insurance

Medical History

Dental History

Authorization

By clicking Submit, I affirm that the information given is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

By clicking Submit, I also authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process dental insurance. I understand that I am responsible for any portion my insurance carrier does not pay.