Toothbud Family Contact and Insurance Form

• Today's Date * MM / DD / YYYY

• Parent or Legal Guardian's Information

  The following information applies to the main legal caregiver of the child / children
• Address
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazil----AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country
• Parent or Legal Guardian's Name
  * First Last
• Relationship to child (children)
  *
• Guardian Birthdate
  * MM / DD / YYYY
• Cell Phone * ### - ### - ####
• Other Phone
  ### - ### - ####
• Email *
• Employer & Occupation
• Guardian Realtionship Status *

  Single Married Divorced

• Spouse or Other Legal Parent or Guardian

• Spouse or Other Legal Parent or Guardian's Name
  First Last
• Relationship to child (children)
• Other Guardian Birthdate
  MM / DD / YYYY
• Other Phone ### - ### - ####
• Employer & Occupation

• Who Will be Accompanying the Child to His/Her Appointment?

  Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
• Person accompanying the child to his/her appointment
  * First Last
• Relationship to child
  *

• Responsible Party / Billing Information

  Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
• Responsible Party's Name
  * First Last
• Social Security Number
  Maximum Allowed: 9 digits.    Currently Used: 0 digits.

  If you prefer to not place your SSN you can enter all 0's and we can get your number over the phone to aid us with insurance verification

• Dental Insurance Information

• Primary Insurance Company's Name
• Primary Insurance Company's Address
• Insurance Company's Phone
  ### - ### - ####
• Insurance ID #
• Group #
• Policy Owner's Name First Last
• Employer
• Birthdate MM / DD / YYYY

•  

• Child's (Children) Physician *
• Physician Phone
  ### - ### - ####
• Signature
• Today's Date * MM / DD / YYYY
• Do Not Fill This Out