Child Patient Registration Form Patient Details

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Child Patient Registration Form Contact Info

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Child Patient Registration Form Mother's Information

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  •  Mother
  •  Stepmother
  •  Guardian

Child Patient Registration Form Father's Information

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  •  Father
  •  Stepfather
  •  Guardian

Child Patient Registration Form Who is Accompanying the Child Today?

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  •  Yes
  •  No

Child Patient Registration Form Person Responsible for Account

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  •  Yes
  •  No

Child Patient Registration Form Primary Dental Insurance

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Child Patient Registration Form Dental History

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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Does the child have any of the following habits?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Insurance
  •  Yelp
  •  Google
  •  Social media
  •  Website
  •  Friend/Family
  •  School
  •  Community/marketing
  •  Doctor
  •  Other

Child Patient Registration Form Health History

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Has the child ever had any of the following conditions?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Good
  •  Fair
  •  Poor

Child Patient Registration Form Authorization and Release

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I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is also my responsibility to inform this office of any changes in my child's medical status. I authorize and request my insurance company to pay directly to the dentist, insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize the dental staff to perform the necessary dental services my child may need.

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The Parent or Guardian who accompanies the child is responsible for payment of time of service unless prior arrangements have been approved.

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