Confidential Patient Information
CHILD
Patient's Legal Name
First Name
Last Name
Preferred Name, if different
First Name
Last Name
Patient's Date Of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
Male
Female
Non-Binary
Patient's Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Dentist
Date of Last Cleaning
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Whom Can We Thank For Referring You?
Please List Any Immediate Family Members Seen In Our Office:
Custodial Parent
First Name
Last Name
Relationship
Father
Mother
Step-Parent
Other
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the patient & guardian live at the same address?
Yes
No
Address, if different than patient
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
Married
Divorced
Single
Widow(er)
Spouse's Name
First Name
Last Name
Relationship To Patient
Father
Mother
Step-Parent
Other
Is there anyone else information regarding your child's account and treatment should be shared with?
Yes
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship To Patient
Do You Have Dental Insurance?
Yes
No
Policy Holder
First Name
Last Name
Date Of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber ID #
Employer
Group #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do You Have a Secondary Insurance?
Yes
No
Policy Holder
First Name
Last Name
Date Of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber ID #
Employer
Group #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Submit
Should be Empty: