Child New Patient Form | Haines Family Dental

Tell Us About Your Child

Today's Date

Child's Name

Nickname

Male

Female

Child's Birthdate

Child's Age

Child's Home Number

Child's Email Address

Child's Home Address

City

State

Zip

Who Is Accompanying The Child Today?

Name

Relation

Whom may we thank for referring you?

Previous / Present Dentist:

Last Visit Date:

Mother's Information

Relation To Child

Biological Mother

Stepmother

Guardian

Name

Birthdate

Email Address

Home Phone Number

Cell Phone Number

Father's Info

Relation To Child

Biological Father

Stepfather

Guardian

Name

Birthdate

Email Address

Home Phone Number

Cell Phone Number

INSURANCE - PRIMARY

Dental Coverage?

Yes

No

Insurance Company Name

Insurance Company Address

Group Number (Plan, Local or Policy Number)

Policy Owner's Name

Relation to Patient

Policy Owner's Birthdate

ID Number

Policy Owner's Employer

Employer's Address

Orthodontic Coverage?

Yes

No

INSURANCE -- SECONDARY

Dental Coverage?

Yes

No

Insurance Company Name

Insurance Company Address

Insurance Company Phone Number

Group Number (Plan, Local or Policy Number)

Policy Owner's Name

Relation to Patient

Policy Owner's Birthdate

ID Number

Policy Owner's Employer

Employer's Address

Orthodontic Coverage?

Yes

No

Emergency Contact

His/Her Name

Relation

Phone Number

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 it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Tell Us About Your Child

Who Is Accompanying The Child Today?

Mother's Information

Father's Info

INSURANCE - PRIMARY

INSURANCE -- SECONDARY

CHILD'S DENTAL HISTORY

CHILD'S MEDICAL HISTORY

Emergency Contact