Child New Patient Form

Patient Information
Is the patient adopted?

Parent 1 Information
Accept Text Messages?
Parent 2 Information
Accept Text Messages?
Primary Dental Insurance Company
Secondary Dental Insurance Company
Do you have secondary dental insurance?
Other Adults Responsible for Care
Any other adults responsible for care?
Medical History Information
Has the patient been under the care of a physician during the past two years?
Please check the following that the patient has been diagnosed with
Have tonsils and adenoids been removed?
Has the patient ever sucked a thumb or fingers?
Has the patient or other family members had any previous orthodontic treatment?
Has the patient been informed of any missing or extra permanent teeth?
Does the patient have any jaw pain or noise in the jaw joint?
Does the patient play a musical instrument (mouth only)?
Other Information
Notice of Privacy Practices Acknowledgment (HIPAA) View/print the Notice of Privacy Practices (HIPAA)

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications.

Signature

My submission of this file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I understand that by entering my name below is the same as signing and that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.