Patient Registration Form | Young and Tann Pediatric Dentistry

CHILD INFORMATION

Child First Name *

Child Last Name *

Birthday (M) *

Birthday (D) *

Birthday (Y) *

Gender *

Street *

City/Town *

Province *

Postal Code *

Health Card Number *

Health Card Expiry *

With Whom Does the Child Reside With *

Child’s Physician *

Physician’s telephone number *

Who may we thank for referring *

Reason for referral *

PARENT/GUARDIAN 1

Parent first name and last name *

Relationship *

Primary Phone Number *

Secondary Phone Number

Email Address *

Address if different from child (Street, City, City/Town, Postal Code)

Employer *

Occupation *

Work Phone *

Dental Insurance Company *

Group #

ID #

ADD A PARENT/GUARDIAN

PARENT/GUARDIAN 2

Parent first name and last name

Relationship

Primary Phone Number

Secondary Phone Number

Email Address

Address if different from child (Street, City, City/Town, Postal Code)

Employer

Occupation

Work Phone

Dental Insurance Company

Group #

ID #

ADD A PARENT/GUARDIAN

PARENT/GUARDIAN 3

Parent first name and last name

Relationship

Primary Phone Number

Secondary Phone Number

Email Address

Address if different from child (Street, City, City/Town, Postal Code)

Employer

Occupation

Work Phone

Dental Insurance Company

Group #

ID #

ADD A PARENT/GUARDIAN

PARENT/GUARDIAN 4

Parent first name and last name

Relationship

Primary Phone Number

Secondary Phone Number

Email Address

Address if different from child (Street, City, City/Town, Postal Code)

Employer

Occupation

Work Phone

Dental Insurance Company

Group #

ID #

I give consent to the release to the release of requested dental records information to appropriate Insurance carriers. This consent includes exchanges of Information, including visual records, to dentist or other agents when such information will benefit patient or be of value in education or research. I further understand that this consent will remain in effect until such time that I choose to terminate it.

Name *

I agree *

Date *