Children'S Pre-Clinical History Form printable pdf download

Children’s Pre-Clinical History

Date: ______________________

Child’s Name: ________________________________________J Male J Female

Nickname: ____________________Social Security #: ______________________

Address: ____________________________________________________________

City:__________________________________State: ________Zip: ____________

Home phone: ________________________Cell phone: ______________________

School: __________________________________Grade: ______________________

Date of Birth: _____/_____/__________________Age: ______________________

Names/ages of brothers/sisters:__________________________________________

____________________________________________________________________

Is this your child’s first dental experience? J yes J no

What is your child’s attitude toward this visit? ____________________________

_____________________________________________________________________

Whom may we thank for referring you to our office?: ______________________

____________________________________________________________________

EMERGENCY INFORMATION

Person to contact: ____________________________________________________

Relationship:____________________________ Phone: ______________________

J I give permission for Boger Dental to share my medical & account information with:

_____________________________________________________________________

DENTAL INSURANCE INFORMATION

Name of Primary Insurance Company: __________________________________

Address: ____________________________________________________________

Phone: ______________________________________________________________

Name of policy holder: ________________________________________________

Relationship to policy holder: J Self J Spouse J Child J Other ______________

Policy holder’s ID/social security #:

____________________________________

Group #:______________________Policy holder’s birth date: _____/_____/_____

Policy holder’s employer: ______________________________________________

Name of Secondary Insurance Company: ________________________________

Address: ____________________________________________________________

Phone: ______________________________________________________________

Name of policy holder: ________________________________________________

Relationship to policy holder: J Self J Spouse J Child J Other ______________

Policy holder’s ID/social security #:

____________________________________

Group #:______________________Policy holder’s birth date: _____/_____/_____

Policy holder’s employer: ______________________________________________

(continued on other side)

I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist has a contractual

agreement with my plan prohibiting all or a portion of such charges, to the extent permitted under applicable law. I authorize release of information

relating to this claim. I also authorize payment of dental benefits, otherwise payable to me, to be paid directly to Stephen P. Boger Dental, DDS, PA.

Parent Signature:________________________________________________________________________________________

APPOINTMENT CANCELLATION POLICY

When you schedule an appointment, we reserve that time and prepare in anticipation of serving you. If you should need to reschedule, we kindly request

that you contact us by phone with advanced notice of two business days. We understand that conflicts arise; however failing your appointment or

canceling without adequate notice more than once will result in a $50 charge and then discontinuation of services. Initials:_________

2720 Annapolis Circle N., Suite A, Plymouth, MN 55441

763-546-7707 phone

763-546-7713 fax