CHILD REGISTRATION
Patient's Name:
*
Child's Birthdate
*
/
Month
/
Day
Year
ex: 01/01/2020
Street Address
*
City
*
State
*
Zip Code
*
Home Phone
Child's Cell Phone (if Applicable)
In case of emergency, who should be notified?
*
Father's Name:
*
Father's Cell Phone
*
Father's Email Address
*
example@example.com
Home Address (if different from child)
Father's Birthdate
*
/
Month
/
Day
Year
ex: 01/01/2020
Dental Insurance Coverage For Child by the Father? If yes, answer the following:
Father's Employer Name
Father's Dental Insurance Company Name & Address
Father's Dental Insurance Company Phone Number
Father's Social Security Number or ID Number
Father's Dental Insurance Group Number
Mother's Name:
*
Mother's Cell Phone
*
Mother's Email Address
*
Mother's Home Address (if different from child)
*
Mother's Birthdate
*
-
Month
-
Day
Year
ex: 01/01/2020
Dental Insurance Coverage For Child By the Mother? If yes, answer the following:
Mother's Employer Name
Mother's Dental Insurance Company Name & Address
Mother's Dental Insurance Company Phone Number
Mother's Social Security Number or ID Number
Mother's Dental Insurance Group Number
Whom may we thank for referring you to this office?
*
Signature of Responsible Party
*
Clear
Today's Date
/
Month
/
Day
Year
ex: 01/01/2020
Submit
Should be Empty: