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Child New Patient Information

Child Registration Form - Dental

Patient Information


 



Have we treated any other immediate family members?
How did you hear about our Practice?

Parent / Guardian Information

Parents' Marital Status


Emergency Contact Information

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information




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.



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Parker Dental

  • Parker Dental - 502 S. Main St., Brownstown, IN 47220 Phone: 812-358-2037 Fax: 812-358-2039

John 15 – "I am the vine; you are the branches. If you remain in me and I in you, you will bear much fruit; apart from me you can do nothing. This is to my Father’s glory."

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