Dental Patient Intake Form

ADVERTISEMENT

WELCOME
to our practice! We strive to make each of your child’s visits pleasant and
comfortable. Our goal is to teach oral habits which will help keep your child’s smile beautiful
for their lifetime.
YOUR CHILD
RESPONSIBLE PARTY
Child’s Name ___________________________
Name __________________________
Nickname ______________________________
Relationship _____________________
Date of Birth ____/___ / _____Age__________
Mailing Address __________________
School _________________________________ _
______________________________
Sex: M______ F________
Physical Address_________________
Child’s mailing address ___________________
_________________________________
______________________________________
________________________________
Phone # ________________________________
Home phone # ____________________
Cell phone # _____________________
DENTAL INSURANCE
Work phone # ___________________
Insured’s Name __________________________
Employer _______________________
Insured’s Employer ______________________
Occupation ______________________
Relationship ___________________________
SSN#__________________________
Date of Birth ___________________________
Insurance Company ______________________
Group # _____________________________
Social Security #_________________________
In the event of an emergency, who should we contact?
Who can we thank for referring
Name _________________________________
you to us?
Relationship ___________________________
_________________________
Phone number ___________________________
FINANCIAL ARRANGEMENTS
Our office will make every effort to provide the best care for your child. You can help us by paying for
dental services upon completion of each visit. IF YOU HAVE INSURANCE, WE WILL BE HAPPY
TO COMPLETE YOUR INSURANCE FORM, BUT PLEASE REMEMBER THAT YOU ARE
ULTIMATELY RESPONSIBLE FOR ALL SERVICES PERFORMED ON YOUR DEPENDENT.
THANK YOU!
X _________________________________
_______________
Signature of Parent / Guardian
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Dental Patient Information Form Dental Patient Information Form Medical
Patient Therapy Patient Intake Form Patient Therapy Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Orthopedic Specialty Institute Patient Intake Form Orthopedic Specialty Institute Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Therapeutic Touch Massage Patient Intake Form Therapeutic Touch Massage Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form - Special Accommodations Patient Intake Form - Special Accommodations Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business

Related Categories

Parent category: Business
Download
Go