Patient's Name *
Patient's Name
Patient's Birthdate *
Patient's Birthdate
Patient's Cell Phone Number (if Applicable)
Patient's Cell Phone Number (if Applicable)
Billing Party
The billing party is the person who will be responsible for and who should be contacted regarding payments. This is most commonly a parent or guardian.
Billing Party's Name *
Billing Party's Name
If applicable, write "Same as Above"
Billing Party's Home Phone Number
Billing Party's Home Phone Number
Billing Party's Work Phone Number
Billing Party's Work Phone Number
Billing Party's Cell Phone Number
Billing Party's Cell Phone Number
Primary Insurance Information
If you have dental insurance, providing the following information will allow us to enter it into the insurance forms for your convenience.
Policy Holder's Name
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's Date of Birth
Secondary Insurance Information
If you have dental insurance, providing the following information will allow us to enter it into the insurance forms for your convenience.
Secondary Policy Holder's Name
Secondary Policy Holder's Name
Secondary Policy Holder's Date of Birth
Secondary Policy Holder's Date of Birth
Growth & Development
Medical & Dental History
Has your child ever had any of the following dental concerns? *
Please select any that apply.
Has your child ever had any of the following medical concerns? *
Please select any that apply.
We will be asking you to sign this form electronically at your child's consultation appointment.