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Patient Registration Form-Child

Eau Claire Family Dental

1018 Regis Court,
Eau Claire, WI, 54701
(715) 832-8063

Patient Information( * mandatory to fill )
  •  Text Message
  •  Email
  •  Cell Phone
  •  Home Phone
PATIENT INFORMATION( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Insurance Information( * mandatory to fill )
  •  Yes
  •  No
ADDITIONAL INSURANCE( * mandatory to fill )
AUTHORIZATION( * mandatory to fill )

 

I certify that I, and/or dependent(s) have insurance coverage and assign directly to this dental office 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.

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