B
A
M
M
D. D. S., F. A. G. D.
R I A N
.
c
U R T R Y ,
Fellow of the Academy of General Dentistry
Child’s Information
Male
Female
Today’s Date: _____________
Patient Name: _______________________________________________________ Nickname: __________________
Last
First
MI
Social Security#:_________________________ Birth Date: ___________________Age: _________________
Address:
_______________________________________________________________________________
Street
Apartment #
_______________________________________________________________________________
City
State
Zip Code
Parent’s/Guardian Information
Parent Name: _________________________________________________________
Last
First
MI
Male
Female
Married
Divorced
Separated
Widowed
Partnered
Single
If Divorced, who is the Legal and Financial Person responsible for your child: _________________________________
Social Security#:______________________________
Birth Date:______________________________________
Phone (Cell:
______________________________
Email Address: __________________________________
Phone (Home): ______________________________
Phone (Work): ___________________________________
Address:
_______________________________________________________________________________
(if different)
Street
Apartment #
_______________________________________________________________________________
City
State
Zip Code
Employer:
Occupation: _____________________________
Referral Information
Whom may we thank for referring you to our practice / How did you hear about us?
Name of person or office referring you to our practice:
________________________________________________
Internet (please circle): Google / Yahoo / Bing / Other. What was search term? ___________________________
New Homeowner Brochure w/magnet
Mountain Island Monitor
School Folder ( MICS , MIE )
Saw our sign driving by
Postcard in mail
Local Sports (Baseball / Soccer)
Little Ones Magazine
Other: ____________________________________________________
Consent for Services / Responsible Party Information
-
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice
depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the
part of each patient must be determined before treatment.
-
I understand I am responsible for any amount not paid by my insurance carrier.
-
I understand that the fee estimate listed for this dental care is valid for a period of six months from the date of the
patient examination.
-
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to
this form and my account.
-
I consent and permit Dr. McMurtry to diagnose any and all dental conditions I may have.
-
By my scheduling subsequent treatment appointments, I consent and give permission to Dr. McMurtry and his staff to
treat the dental conditions previously diagnosed.
I have read the above conditions of treatment and payment and agree to their content.
____________________________________________________ Date: _____________ Relationship to Patient:
Signature of patient, parent or guardian