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Child New Patient Information

Parent / Guardian Information

Parent 1

Parent / Guardian Information

Parent 2

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

Medical History

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

CareCredit

CareCredit is a healthcare credit card designed for your health and wellness needs. Pay for the costs of many treatments and procedures through convenient monthly payments.

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