Child Patient Form

Insurance Information
Parent/Guardian Initials
Date
Insured's Name
Insured's SSN or IDN
Insured's Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
- Yes
- No
If yes, benefit amount:
If you have secondary insurance
Insured's Full Name
Insured's First Name Insured's Middle Name Insured's Last Name
Insured's Employer
Social Security Number
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
- Yes
- No
If yes, benefit amount:

Emergency Information
Name of nearest relative not living with you
Relative's First Name Relative's Middle Name Relative's Last Name
Relative's Phone Number
Relative's Address
Street Address Address Line 2 City State ZIP Code

NEW PATIENT FORM