Registration Form - Child

Please correct the errors described below.

PERSON RESPONSIBLE FOR THIS ACCOUNT

FOR PATlENTS COVERED BY DENTAL INSURANCE

If Covered By More Than One Plan, Fill Out Next Section

Please choose the appropriate answer

8. Does your child have (or ever had) any of the following disease?

17. ls he / she taking any of the following?

18. ls he/she allergic to, or has he/she ever reacted adversely to any of the following?

ADOLESCENT WOMEN

To the best of my knowledge, all of the preceding answers are true and correct. lf I ever have any change in my health, or if my medicines change, I will inform the dentist at the start of the next appointment.

Also, the undersigned hereby authorizes the taking of x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs (after discussing these with the patient). I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand the office may request information from, or report information to a credit rating institution.

FOR OFFICE USE ONLY

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