Child New Patient Registration

Tell Us About Your Child

General Information

Who is accompanying the child today?

Do you have legal custody of this child?

Relative or Friend not living with you

Parent's Information

Authorization

This office reserves the right to verify the credit status of potential patients and/or parents of the patient prior to extending credit for treatment fees and may at the discretion of this office, use the services of one or more credit reporting services. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submission, whether manual or electronic.

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.

Dental and Medical History

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, The CDC and the ADA.

I understand that the information I have given is correct to the best of my knowledge. That it 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, I authorize the dental staff to perform the necessary dental / Orthodontic services my child may need

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.

OFFICE USE ONLY

I have verbally reviewed the medical/dental information above with the parent/guardian & patient named herein.

MEDICAL HISTORY UPDATE

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.