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Patient Registration Form.

Art of Modern Dentistry

1339 S Michigan Av,
Chicago, IL, 60605
(312) 922-1898

PATIENT INFORMATION( * mandatory to fill )

We are pleased to welcome you and your child Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward to working with you in maintaining your child's dental health.

INSURANCE( * mandatory to fill )
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DENTAL HISTORY( * mandatory to fill )
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MEDICAL HISTORY( * mandatory to fill )
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Do you have, or have you had, any of the following?
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Emergency Contact Information( * mandatory to fill )

In the event of an emergency. whom should we contact?

AUTHORIZATION( * mandatory to fill )

 

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.

Minor/Child Consent

I am the parent, guardian, or personal representative of

and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to X-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance with

and assign directly to Dr. John Doe all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

 The above-named doctor may use my minor/child's health care information and may disclose such information to the above-named Insurance Company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

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