Child New Patient Information

Date - mm/dd/yyyy

Patient Name (First and Last)

Prefer to be called

Male Female

Birthdate - mm/dd/yyyy

Age

Address

City

Province

Postal Code

Primary Phone Number

email address

List any family members that are patients in our office

How did you hear about our office Dentist Phonebook Internet Friend Relative
Other

Whom may we thank for referring you to our office?

Parent/Guardian Information

Emergency Contact

Insurance Information

Person responsible for the account

Do you have an insurance plan that covers orthodontic treatment? Yes
No
Not Sure

Primary Insurance Name

Policy Holder Name

Policy Holder Address (if different from child)

Policy Holder Phone Number (if different from child)

Policy Holder Birthdate - mm/dd/yyyy

Relationship to patient

Group/Policy number

ID/Certificate Number

Lifetime Maximum

Percentage Payable

What is the Age Restriction

Secondary Insurance Name

Policy Holder Name

Policy Holder Address (if different from child)

Policy Holder Phone Number (if different from child)

Policy Holder Birthdate - mm/dd/yyyy

Relationship to Patient

Group/Policy Number

ID/Certificate Number

Lifetime Maximum

Percentage Payable

What is the Age Restriction

Dental History

Medical History

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.
Agree
Responsible Party Signature