Mountain Kids Pediatric Dentistry Patient Information
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2Mountain Kids Pediatric Dentistry
Patient Information
Child’s Name:____________________________________________________________________________________________________________
Last
First
Sex: M/F
Date of Birth
Age
SSN/Medicaid #
Child’s Name:____________________________________________________________________________________________________________
Last
First
Sex: M/F
Date of Birth
Age
SSN/Medicaid #
Child’s Name:____________________________________________________________________________________________________________
Last
First
Sex: M/F
Date of Birth
Age
SSN/Medicaid #
Child’s Name:____________________________________________________________________________________________________________
Last
First
Sex: M/F
Date of Birth
Age
SSN/Medicaid #
Child’s Name:____________________________________________________________________________________________________________
Last
First
Sex: M/F
Date of Birth
Age
SSN/Medicaid #
Responsible Party Information
*The parent or guardian that signs this paperwork is the Responsible Party or Guarantor of financial account. This may be different than the provider of insurance.*
Name: __________________________________________________________________________________________________________________
Last
First
Date of Birth
SSN
Marital Status
Relationship to patient
____________________________________________________________________________________________________________
Address (street, city, state, zip code)
email address
_____________________________________
_____________________________________
_____________________________________________
Home phone
Cell phone
Work phone
____________________________________________________________________________________________________________
Employer
Employer Address
Years employed
____________________________________________________________________________________________________________
Guarantor Signature
Date
Other persons authorized by guarantor to have access to HIPAA protected financial information regarding the account and/or seek treatment for
your child(ren). All authorized persons must identify themselves to staff. Please check boxes (□) for emergency contacts.
□
Other Parent Name: _____________________________________________________________________________________________________
Last
First
Date of Birth
SSN
Marital status
Relationship to patient
____________________________________________________________________________________________________________
Address (street, city, state, zip code)
email address
_____________________________________
_____________________________________
_____________________________________________
Home phone
Cell phone
Work phone
□
Other: ________________________________________________________________________________________________________________
Last
First
Relationship to patient
Phone
□
Other: ________________________________________________________________________________________________________________
Last
First
Relationship to patient
Phone
Insurance Information
If you expect insurance to pay for services, please make sure to present insurance card. You must inform us of any changes when
calling to schedule appointments.
Subscriber Information: ________________________________________________________________________________________
Last
First
Date of Birth
SubscriberID/SSN
Relationship to patient
__________________________
______________________
____________________
_____________________
Employer Name
Insurance Company
Insurance Phone Number
Group Number
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Parent category: Medical