Palatine Pediatric Dentistry

Thank you for choosing our office for your child's dental care. All information in this form is confidential. If your child is covered by a dental insurance plan we would appreciate you entering all of the requested information in the insurance section of the form. Your cooperation will allow us to verify the insurance and obtain the extent of coverage. This will help us to quickly process your child’s registration and more easily answer some of the coverage questions you may have. Your reply will be transmitted over a secure, encrypted connection and will not be sold to any third party.

(*) indicates a required field
  • Tell Us About Your Child

  • Although this question is optional it will help us communicate with and get to know your child better.

  • Parent or Legal Guardian's Information

    The following information applies to the main legal caregiver for the above named child (where the child lives)

  • - -

  • - -
  • Please type in numbers only with no spaces or "-" dashes.

  • If an individual or medical or dental professional referred you, we'd like to thank them.

  • Spouse or Other Legal Parent or Guardian

  • - -
  • - -
  • Please type in numbers only with no spaces or "-" dashes.

  • 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.
  • Do you have legal custody of this 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.
  • - -
  • - -
  • Dental Insurance Information

  • - -
  • Please type in numbers only with no spaces or "-" dashes.

  • Dual Insurance Coverage?

    Please complete the following information if you have secondary dental coverage for your child.
  • Do you have dual (secondary) insurance coverage?

  • - -
  • Please type in numbers only with no spaces or "-" dashes.

  • Child's Health History

  • Is your child experiencing or have they ever experienced any of the following conditions? *

    Please check any fields that relate to your child

  • - -
  • Is your child currently being monitored by a physician for any reason other then routine care? *
  • Please describe your child's current physical health *
  • Dental History

  • Is this your child's first visit to the dentist? *
  • Check any of the habits your child may have.
  • Is your child currently using or have a history of tobacco use?
  • Check any of the following that apply to your child