Longhorn Pediatric Dentistry & Orthodontics 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
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.
Parent or Legal Guardian's Home Address *
3. Spouse or Other Legal Guardian's Information
(If different from #2 above.)
Spouse or Other Legal Guardian's Home Address
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.
6. Person Responsible for Account
7. Primary Dental Insurance
8. Dual (Secondary) Insurance
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.)