Child's New Patient Information

Name of Minor / Child

Age

Date of Birth

Nickname

Hobbies

Home Address

Mailing Address

Person Financially Responsible

Home Phone No.

Work Phone No.

Who may we thank for referring you

INSURANCE

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DENTAL HISTORY

Date of last visit to a dentist

For what service?

MEDICAL HISTORY

Minor/Child's Physician

City / State

Phone No.

Date of last physical examination

Results

Medications

Allergies

EMERGENCY CONTACT

In the event of an emergency, whom should we contact?

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AUTHORIZATIONS

The information that | have given is correct to the best of my knowledge. I understand that it will be held in the strictest of 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 services for my minor/child.

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.

Signature of Parent/Guardian

Date

I certify that my minor/child is covered by insurance with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that | am financially responsible for all charges whether or not paid by insurance. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature of Parent/Guardian

Date

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