New Patient Family Information

We are a chartless office and when you come to your appointment we will have you fill out detailed information about the patient in the computer. In order to have your wait time as short as possible, please fill out this form with insurance, patient family and general information and submit it to our office so we may enter this information beforehand. We look forward to seeing you at your appointment.

Patient's first and last name:
Birth Date:

Email address:
Responsible party's name:
Responsible party's date of birth:
Street Address:
Apartment/Suite Number:
City:
State:
Zip:
Home Phone Number:( ) -
Cell Phone Number:( ) -

In case of emergency (someone that does NOT live with child):
Name:
Number:( ) -

Parent's Dentist:

Parent's Dental Health:
Mom:
Dad:

Child's Previous DDS:
Describe their experience:

Parent's Marital Status:

Is Child Adopted:
If yes, do you have legal documentation?

Name of child's school:
Name of child's pediatrician:
Pediatrician's phone number:( ) -
Who may we thank for referring you?

Insurance Information

Insurance name:
Policy holder's name:
Policy holder's address (if different from child):

Policy holder's phone number:( ) -
Policy holder's DOB:
Company (employer):
Policy/Group number:
ID Number:
Insurance Phone Number:( ) -