Child New Patient Form
Whom may we thank for referring you to our office?
Date
Patient's First Name
Patient's Last Name
Nickname
Age
Address
City
State
Zipcode
Home Phone
Cell Phone
email
Birth Date
Sex
Driver License
Social Security #
Dentist
Dentist Phone #
MD Name
MD Phone #
If minor, Mother's name
Father's name
If minor, who does patient live with
RESPONSIBLE PARTY INFORMATION
First name
Last name
Address
Home Phone
Cell Phone
Work Phone
Email
Relationship to patient
birth date
social security #
employer
Spouse's First Name
Spouse's Last Name
home Phone
Cell Phone
work phone
email
relationship to patient
birth date
social security #
employer
INSURANCE INFORMATION
Insured's First Name
Insured's Last Name
Insured's Birth Date
Insurance Company
Insurance Company Address
Phone Number
Insurance ID#
Do you have dual coverage? If YES, please complete the following insurance info:
NO
YES
Insured's First Name
Insured's Last Name
Insured's Birth Date
Insurance Company
Insurance Company Address
Phone Number
Insurance ID#
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
Emergency Contact Phone
Relative Living With You
This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered. I further understand that if a payment becomes 30 days past due, a $5.00 late fee will be assessed. I hereby authorize the release of medical information, if necessary, and payments from the above mentioned insurance company to go directly to Dr. Paul Serrano/Serrano & Kyger Family Orthodontics. I also understand I am responsible for any balance that my insurance company does not pay. I am aware that when appropriate, this office may request a credit history profile.
Responsible Party Signature
date
Location
Phoenix Office
Chandler Office
or
Be sure to bring the printed form with you on your first visit.
