Parent Information Patient Details

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Parent Information Parent's Informatiom

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Parent Information Insurance Information

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Primary Insurance:

  •  Yes
  •  No

Secondary Insurance:

  •  Yes
  •  No

Parent Information

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If you have any questions about this form or are unsure how to answer any questions, we’d be happy to assist you. Please ask!

Authorization:

I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate dental treatment for my child and that providing incorrect information can be dangerous for my child’s health. If there is any change in my child’s medical status, I will inform the dentist. I authorize Growing Smiles Pediatric Dentistry, P.C. to release any information including diagnosis, and the records of any treatment or exam rendered to my child during the period of such dental care, to third party payers and/or their healthcare practitioners.

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