• Child Patient Information

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  • Person Responsible For Account

    Person #1
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  • Person Responsible For Account

    Person #2
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  • Emergency Contact Information

  • Primary Dental Insurance Information

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  • Secondary Dental Insurance Information

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  • Dental History

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  • Medical History

  • Authorization

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
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  • Should be Empty: