Child Registration Form

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We would like to welcome you to our office. In an effort to provide the best service, we ask you to fill out this form as completely as possible.

Thank you!

* required field

Child Registration Form

Patient Information

RESPONSIBLE PARTY INFORMATION

Parent/Guardian Information

Parent/Guardian Information

DENTAL INSURANCE INFORMATION

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

DENTAL HISTORY

EMERGENCY CONTACT

PURPOSE OF CONSENT

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences, and it is my responsibility to inform this office of any changes in the patients medical status. I understand, where appropriate, credit bureau reports may be obtained.