loomisfamilydentist.com - CHILD REGISTRATION FORM

CHILD REGISTRATION FORM
Patient's Name
Preferred Name
Birthdate

MonthDayYear
Date
Age
Gender

MaleFemale
Social Security Number
Father’s Name
SS#
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Cellular Phone #
Please enter a valid phone number.
Employer
Position
How Long?
Employer Address
Phone Number
Please enter a valid phone number.
Marital Status:

SingleMarriedWidowedDivorcedSeparated
Mother's Name
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Cellular Phone #
Please enter a valid phone number.
Employer
Position
How Long?
Employer Address
Phone Number
Please enter a valid phone number.
Marital Status:

SingleMarriedWidowedDivorcedSeparated
Who should we notify, other than spouse, in case of emergency?
Name
Relationship
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Dentist
Phone Number
Please enter a valid phone number.
How did you hear about our office?

Phone Book – Quest DexFamily Member:Phone Book – Yellow BookDoctor’s Office:InsuranceWebsiteOther: (Please specify)
Family Member:
Doctor’s Office: Dr. Name
Payment information: All services must be paid by cash, check or credit card as each service is provided. Patients with insurance or other coverage must complete all required information
Primary Insurance:
Subscriber’s Name
SS #
Relationship of Patient:

SelfSpouseChild
Birthdate

MonthDayYear
Date
Insurance Company
Insurance Company
Phone Number
Please enter a valid phone number.
Address
Secondary Insurance:
Subscriber’s Name
SS #
Relationship of Patient:

SelfSpouseChild
Birthdate

MonthDayYear
Date
Insurance Company
Group #
Phone Number
Please enter a valid phone number.
Address
AUTHORIZATION FOR RELEASE OF INFORMATION: (All patients/guarantors must sign) I certify that the above information is correct. I authorize release of any information relating to my dental claims. I understand that I am responsible for all costs of dental treatment, I hereby authorize payment of the group insurance benefits otherwise payable to me directly to Loomis Family Dental.

PERMISSION FOR TREATMENT: (All patients/guarantors must sign) I hereby give my permission to Loomis Family Dental dentists to provide dental treatment as deemed necessary.

PAYMENT AGREEMENT: (All patients/guarantors must sign) I understand that my Insurance Policy is between the insurance company and myself and I am liable to Loomis Family Dental for services rendered. I also understand I will be furnished with an estimate regarding my insurance benefits at the onset of treatment. I agree to pay Loomis Family Dental for all dental treatment at the time of service. I promise to pay my account until my balance has been paid in full. Should my account become past due, I will be charged 1.5% per month interest with $25.00 late charge fee on the overdue amount. I also understand that should my account become delinquent, it may be turned over for collection, including any attorney’s fees incurred.
Patient Signature

Clear
Date

MonthDayYear
Date
Please remember that once an appointment has been made, this time is reserved specially for you. No charge will be made for rescheduling an appointment, provided early notice of at least 1 business day is given. Otherwise minimum charge of $50 per hour scheduled may be incurred. We reserve the right to not reschedule your appointment.
Should be Empty:

CHILD REGISTRATION FORM

Primary Insurance:

Secondary Insurance: