Child Patient Information

  • Patient Information
  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian Information
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Emergency Contact
  • Insurance Information
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Dental History
  • Medical History
  • Date Format: MM slash DD slash YYYY
  • Authorization
  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
  • Date Format: MM slash DD slash YYYY
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