Just for Kids New Patient Dental/Health Form
We sincerely welcome you and your child into our practice We will make you rdental visits as pleasant as we can. In order for us to better understand your child, please complete this form as thoroughly as possible. Thank you.
(*) indicates a required field.
Dental Insurance Information
Has your child had or does he/she have now:
Person to contact in case of emergency (not living at home)
In order to provide your child with optimum care, we draw upon the knowledge of the entire staff of doctors in consultation, diagnosis and treatment of all patients. The undersigned hereby authorizes this dental office to perform the examination and after explanation, the necessary dental services deemed appropriate for the care of the above named child and furthermore, will be responsible for charges incurred from said dental patient.
Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)