loomisfamilydentist.com - CHILD REGISTRATION FORM

CHILD REGISTRATION FORM
Patient's Name
Preferred Name
Birthdate

MonthDayYear
Date
Age
Gender
Social Security Number
Father’s Name
SS#
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cellular Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Position
How Long?
Employer Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status:
Mother's Name
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cellular Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Position
How Long?
Employer Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status:
Who should we notify, other than spouse, in case of emergency?
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Dentist
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office?

Other: (Please specify)
Family Member:
Doctor’s Office: Dr. Name
Payment information: All services must be paid by cash, check or credit card as each service is provided. Patients with insurance or other coverage must complete all required information
Primary Insurance:
Subscriber’s Name
SS #
Relationship of Patient:
Birthdate

MonthDayYear
Date
Insurance Company
Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Secondary Insurance:
Subscriber’s Name
SS #
Relationship of Patient:
Birthdate

MonthDayYear
Date
Insurance Company
Group #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
AUTHORIZATION FOR RELEASE OF INFORMATION: (All patients/guarantors must sign) I certify that the above information is correct. I authorize release of any information relating to my dental claims. I understand that I am responsible for all costs of dental treatment, I hereby authorize payment of the group insurance benefits otherwise payable to me directly to Loomis Family Dental.

PERMISSION FOR TREATMENT: (All patients/guarantors must sign) I hereby give my permission to Loomis Family Dental dentists to provide dental treatment as deemed necessary.

PAYMENT AGREEMENT: (All patients/guarantors must sign) I understand that my Insurance Policy is between the insurance company and myself and I am liable to Loomis Family Dental for services rendered. I also understand I will be furnished with an estimate regarding my insurance benefits at the onset of treatment. I agree to pay Loomis Family Dental for all dental treatment at the time of service. I promise to pay my account until my balance has been paid in full. Should my account become past due, I will be charged 1.5% per month interest with $25.00 late charge fee on the overdue amount. I also understand that should my account become delinquent, it may be turned over for collection, including any attorney’s fees incurred.
Patient Signature
Date

MonthDayYear
Date
To ensure that we can provide timely care to all patients, we require adequate notice of appointment changes. A missed appointment fee of $75.00 per hour of scheduled time may be assessed if an appointment is missed or canceled without sufficient notice. For purposes of this policy, sufficient notice is defined as at least 48 business hours prior to the scheduled appointment time. This fee is intended to offset the cost of lost appointment time and may not be covered by dental insurance. Repeated missed or late-canceled appointments may result in dismissal from the practice. Exceptions may be made in the event of unforeseen emergencies, at the discretion of the provider.
Should be Empty:

CHILD REGISTRATION FORM

Primary Insurance:

Secondary Insurance: