Patient Information Form For Patients Under 18 Years Of Age Form printable pdf download

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

Date___________________

_____________________________________________________________________________________

Patient’s name

Last

First

Middle

Address _____________________________________________________________________________________________________

Street

City

Zip

Nickname______________________ Birthdate_______________ Social Security # ________________________________________

School___________________________ Sports/Hobbies ______________________________________________________________

Parent or guardian name _______________________________________________________________________________________

Whom may we thank for referring you to our office? __________________________________________________________________

RESPONSIBLE PARTY INFORMATION

Name_______________________________________________________________________________________________________

Last

First

Middle

Residence ___________________________________________________________________________________________________

Street

City

Zip

Mailing Address_______________________________________________________________________________________________

Street

City

Zip

How long at this address?______ Home phone_________________________ Work phone __________________________________

Cell/other phone_________________________ Email address _________________________________________________________

Previous Address (If less than 3 years) ____________________________________________________________________________

Social Security #_____________________________ Birthdate_________________ Relationship to Patient _____________________

Employer_____________________________________ Occupation____________________ No. years employed ________________

Spouse’s Name_____________________________________________ Relationship to Patient _______________________________

Employer_____________________________________ Occupation____________________ No. years employed ________________

Social Security # _________________________________Birthdate _____________________Work Phone______________________

DENTAL INSURANCE INFORMATION

Insured’s Name___________________________________________ Insured’s Social Security # ______________________________

Insurance Company_________________________ Group No._________________ Local No. ________________________________

Insurance Co. Address_________________________________________________ Phone No. _______________________________

Do you have dual coverage?

Yes_____

No_____

If yes:

Insured’s Name________________________________________ Insured’s Social Security # _________________________________

Insurance Company_________________________ Group No._________________ Local No. ________________________________

Insurance Co. Address_________________________________________________ Phone No. _______________________________

EMERGENCY INFORMATION

Name of nearest relative not living with you _________________________________________________________________________

__________________________________________________________________________________

Complete address

Street

City

Zip

Phone ______________________________________________________________________________________________________

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

Parent Signature _________________________________________________________________________________________________

Updates (date & initial) _____________________________________________________________________________________________

Patient Information Form For Patients Under 18 Years Of Age Form

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