Child Registration Form - Dental
* required field

Patient Information



Parent / Guardian Information

Parents' Marital Status

Emergency Contact

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information

Dental History

How did you hear about our Practice?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?

Medical History

Is your child currently being treated by a physician?

Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has your child had any serious illnesses or operations? If yes, describe:

Check if your child has or has ever had any of the following:


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. 

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