Child Patient Information

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Child Patient Information
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Patient Information

Gender





Primary Phone Number
Full-Time Student?


Parent/Guardian Information

Relation





Phone Number
Secondary Phone Number

Emergency Contact




Primary Insurance Information









Secondary Insurance Information









Dental History

How did you hear about our Practice?




Are you please with the appearance of your teeth?
Are any of your teeth sensitive to hot, cold, or sweet items?
Do your gums bleed when brushing?
Have you had Periodontal (Gum) treatment?
Have you noticed any problems of the jaw-clicking or popping?

Notice of Privacy & Consent

A copy of our Notice of Privacy Policy is located on our website. We encourage you to review it carefully. By signing this form, you are consenting to our use of disclosure of your protect health information to carry out treatment, payments activates, and healthcare operations


Assignment & Release

I, the undersigned certify that I (or my dependent) have insurance coverage through the about notes insurance company and assign directly to Maplewood Dental Associates, P.A. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all insurance submissions.




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