Pham Child Registration Form

1

About Your Child

Today's Date:

Child's Name:

LAST

FIRST

MI

Birthdate: / / Age: Male Female

Child's Home #: ()

Child's Home Address:

STREET ADDRESS

CITY

STATE

ZIP

2

General Information

Who is accompanying the child today?
Name: Relation:

Do you have legal custody of this child? Yes No

Whom may we thank for referring you?

Siblings:

Previous Dentist:

Last Visit Date:

Dentist's Phone #: ()

3

Parent's Information

Person Responsible for Account:

Name: Birthdate: / /

Address (if different than child's) Home #: ()

Wk. #: () Ext: Cell #: ()

Email Address:

Employer:

Occupation:

If you have insurance for your child, please fill out below:

Name of insured: Birthdate: / /

SS #: DL #:

Insurance Co: Insurance Address:

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

Name: Birthdate: / /

Address (if different than child's) Home #: ()

Wk. #: () Ext: Cell #: ()

Email Address:

Employer:

Occupation:

If you have insurance for your child, please fill out below:

Name of insured: Birthdate: / /

SS #: DL #:

Insurance Co: Insurance Address:

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

** TO MINIMIZE YOUR COPAYMENTS, YOU MUST PROVIDE ALL INSURANCE PLANS YOU ARE CURRENTLY ENROLLED IN. WE WILL ONLY BE BILLING THE INSURANCE PLANS THAT WERE PROVIDED AT THE TIME SERVICES WERE RENDERED.

6

INFORMED CONSENT

I certify that my child is covered by the above insurance plan(s)and I assign all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover.
I hereby authorize the doctor and his/her staff to perform all dental diagnostic procedures on my child including x-rays, cleaning and topical fluoride treatment unless I have specifically made other arrangements in writing.

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

Signature of parent or guardian

Date