CHILD REGISTRATION
Patients Name
*
First & Last name
Birthdate
*
Ex: 01/01/2020
Street Address
*
Home Phone
*
Ex: 610-123-4567
City
*
State
*
Zip Code
*
In case of emergency, who should be notified?
*
Father's Name
Address (if different from child)
Home Phone
Ex: 610-123-4567
Cell Phone
Ex: 610-123-4567
Work Phone
Ex: 610-123-4567
Is there Dental Insurance Coverage for child by the father?
If yes, answer the following information below
Employer Name
Insurance Company Name and Address:
Insurance Company Phone Number
Ex:1-800-123-4567
Group #
Father's Social Security Number
Only required if needed for submission of insurance claim Ex: 123-45-6789
ID #
Father's Birthdate
Ex: 01/01/2020
Mother's Name
Address (if different from child)
Home Phone
Ex: 610-123-4567
Cell Phone
Ex: 610-123-4567
Work Phone
Ex: 610-123-4567
Is there Dental Insurance Coverage for child by the mother?
If yes, answer the following information below
Employer Name
Insurance Company Name and Address:
Insurance Company Phone Number
Group #
Social Security Number
Only required if needed for submission of insurance claims Ex: 123-45-6789
ID#
Mother's Birthdate
Ex: 01/01/2020
Whom may we thank for referring you?
*
Signature of Responsible Party:
Clear
Date
/
Month
/
Day
Year
Date
COMMENTS:
Submit
Should be Empty: