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
Single Married Divorced Widowed

Parent or Legal Guardian's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Employer

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
Single Married Divorced Widowed

Spouse or Other Legal Guardian's Home Address

Street Address

Apt #

City

State

Zip Code

Employer

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 *

Do you have legal custody of this child? *
Yes No

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?
Yes No

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.

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

Relationship to Patient *

Date *