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Child New Patient Form

Welcome to our practice! We strive to make each of your child’s visit pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their lifetime.

Your Child

 

  Sex:

 

   

  Parents Marital Status:

Responsible Party

 

   

 

Mother

  Status:

       

   

Father

  Status:

       

   

Primary Insurance

   

 

 

 

   

   

Orthodontic coverage? YesNo

Do you have any additional insurance? YesNo

Who is responsible for making appointments?

       

 

Authorization and Release

To the best of my knowledge, the questions on this for have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I authorized the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental group insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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When you've finished this form please fill out the Child Health History Form.

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Bedford Family & Laser Dentistry