Orthodontic Child Registration Form

Tell Us About Your Child

Today's Date: Nickname:

Child's Name:

LAST

FIRST

Birthdate: / / Age: Male Female

School: Grade:

Hobbies / Sports:

Child's Home #: ()

Child's Home Address:

STREET ADDRESS

CITY

STATE

ZIP

Person Responsible For Account

Name: Relation:

Billing Address:

STREET ADDRESS

CITY

STATE

ZIP

Do You? Own or Rent How Long?

Hm # () DL #

Cell # () SS #

Employer: Wk # () Ext

Who is responsible for making appointments?

Name:

Wk # () Ext HM # ()

Primary Orthodontic Insurance

Orthodontic Coverage? Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone: ()

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate: / / ID #:

Policy Owner's Employer:

Employer's Address:

Secondary Orthodontic Insurance

Orthodontic Coverage? Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone: ()

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate: / / ID #:

Policy Owner's Employer:

Employer's Address:

Acknowldgement / Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my resposibility to inform this office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need

Signature of parent or guardian

Date

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

Signature of parent or guardian

Date

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature of parent or guardian

Date

The parent or Guardian who accompanies the child is responsible for payment.
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviews the medical / dental information above with the parent / guardian and patient named herein.

Initials: Date:

Doctor's Comments:

Patient Validation: