New Patient Financial/Insurance Form

Thank you for choosing our office for your child's/children’s dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

If the information in this form is the same for each child, please complete only one form. If information varies for children in your family, please complete additional financial/insurance forms as needed.

(*) indicates a required field.

1. Tell Us About Your Child/Children

Today's Date *

Child's Name *

Date of Birth *

Child's Name

Date of Birth

Child's Name

Date of Birth

Additional Children and/or Comments

2. Parent or Legal Guardian's Information

The information in this section applies to the main legal caregiver of the child / children.

Name *

Relationship to Child *

Birthdate *

Marital Status
     


Parent or Legal Guardian's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


Employer


Occupation

Work Number

Home Number *

Cell Number

Social Security Number *

Driver's License Number

Email Address *

3. Spouse or Other Legal Guardian's Information

(If different from #2 above.)

Name

Relationship to Child

Birthdate

Marital Status
     


Spouse or Other Legal Guardian's Home Address

Street Address

Apt #

City

State

Zip Code


Employer


Occupation

Work Number

Home Number

Cell Number

Social Security Number

Driver's License Number

Email Address

4. How Did You Learn About Our Practice?


5. Who Will Be Accompanying the Child/Children to Their Appointment?

Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.

Name *

Relationship *

In case of an emergency, whom should we contact?

Name *

Phone *

Do you have legal custody of this child? *

6. Person Responsible for Account

Name *

Relationship *

Billing Address (If Different)

Apt #

City

State

Zip Code

Work Number

Home Number

Cell Number

Email Address

7. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Insurance ID #

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

8. Dual (Secondary) Insurance

Do you have dual (secondary) insurance?

Insurance Company Name

9. Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes.

Late Charges: If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies and prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding balances.

Authorization and Release: I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to my child during the period of such dental care to third party payers and/or other health practitioners. I authorize and request my dental insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Relationship to Patient *

Date *