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  • Secure Patient Registration Form

  • We want to welcome your child into our practice. Our goal is to make his/her dental experience pleasant and educational. Please provide us with all information requested so that we can better understand and care for your child. 

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  • Health Information:

  • Has your child ever had difficulty with any of the following: (Please check all that apply) 

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  • Because your child is a minor, it is necessary that signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment is performed. The signature of a parent or guardian affixed below authorizes the completion of all agreed upon dental treatment and the use of those methods appropriate there to. This consent shall remain in full force and effect until cancelled by either party. Furthermore, the undersigned agrees to be responsible for any bill incurred on this child for dental treatment should named responsible party fail or insurance benefits be denied. 

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  • Who is Accompanying the Child today?

  • I have listed below two persons who might be involved in his/her dental updates and/or transportation

  • Parent or Guardian Information

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  • Emergency Information

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  • Primary Insurance Information

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  • Referral Information

  • I authorize the dentist to release any information to third party payers and /or other health practitioners, if necessary. I authorize and request my insurance company to pay directly to the dentist benefits otherwise payable to me. 

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  • Should be Empty: