Toothbud Family Contact and Insurance Form

Thank you for choosing Toothbud for your child's / children's dental home. This first form only needs to be completed one time per family. All information in this form is confidential and transmitted over asecure, encrypted connection and will not be sold to any third party.

Parent or Legal Guardian's Information

The following information applies to the main legal caregiver of the child / children

Address 1

Address 2

City

State

Zip Code

Country

Parent or Legal Guardian's Name

Relationship to child (children)

Guardian Birthdate

Cell Phone No.

Other Phone No.

Email address

Employer Name

Employer's Occupation

Guardian Realtionship Status

Single Married Divorced

Spouse or Other Legal Parent or Guardian

Spouse or Other Legal Parent or Guardian's Name

Relationship to child (children)

Other Guardian Birthdate

Other Phone

Employer Name

Employer's Occupation

Who Will be Accompanying the Child to His/Her Appointment?

Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.

Person accompanying the child to his/her appointment

Relationship to child

Responsible Party / Billing Information

Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.

Responsible Party's Name

Social Security Number

Maximum Allowed: 9 digits. Currently Used: 0 digits.

Dental Insurance Information

Primary Insurance Company's Name

Primary Insurance Company's Address

Insurance Company's Phone

Insurance ID #

Group #

Policy Owner's Name

Employer

Birthdate

Child's (Children) Physician

Physician Phone

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature

Date

Your information will be encrypted.