Patient Registration Form Child Tell Us About Your Child

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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Patient Registration Form Child Parent Information

Patient Registration Form Child Dental Insurance Information

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Patient Registration Form Child Medical History

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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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Patient Registration Form Child Dental History

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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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Patient Registration Form Child ACKNOWLEDGEMEMT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I

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

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