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Patient Registration Form Child

State Street Smiles

405 Main Street,
Hackensack, NJ 07601
(201) 487-7030

Tell Us About Your Child( * mandatory to fill )

Welcome!

We would like to welcome you and your child to our office. The benefits of a happy, healthy smile are immeasurable. Our philosophy is to provide each patient with the highest quality dental care in a fun-filled and friendly environment. Please take a moment to fill out this form completely. The better we can communicate, the better we can care for you.

Who is Accompanying the Child Today?

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Parent Information( * mandatory to fill )
Dental Insurance Information( * mandatory to fill )
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  •  No
Medical History( * mandatory to fill )
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Does your child have a history of any of the following medical problems (check all that apply)

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Dental History( * mandatory to fill )
  •  Yes
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Consent

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and that it is my responsibility to inform this office of any changes in my childs medical status without fail. It is necessary, because my child is a minor that permission be obtained from a parent or guardian before necessary treatment is performed. My signature affixed below authorizes the dentists of State Street Smiles and their staff to provide my child dental and related medical/surgical treatment as deemed necessary. Utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete such treatment, including diagnostic radiographs. I authorize the dentist to release any information including the diagnosis and the record of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group 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 understand that it is my responsibility to know the terms of my dental insurance contract (i.e. How often my insurance carrier will pay for exams and cleanings). This consent shall remain in full force and in effect until canceled by either party. I fully understand this authorization and have no further questions.

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CREDIT CARD CONSENT( * mandatory to fill )

In order to minimize costs for our patients we require a credit card one file for future balances.

hereby consent to have State Street Smiles charge the provided credit card for balances up to $100 per family member.

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ACKNOWLEDGEMEMT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

I

have received a copy of this office Notice of Privacy Practices.

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