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New Patient Information
Medical History, Dental History, and Insurance Information
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* Indicates required question
Patients Full Name*
*
Your answer
Child's date of birth
*
MM
/
DD
/
YYYY
Child lives with (check all applicable):
*
Mother
Father
Granparent
Stepmother
Stepfather
Other:
Required
Is your child adopted?
*
Yes
No
Mother's Name (or please type NA if not appicable)
*
Your answer
Mother's Social Security Number (or please type NA if not applicable)
*
Your answer
Mother's date of birth (necessary for insurance billing purposes)
Your answer
Father's Name (or please type NA if not applicable)
*
Your answer
Father's Social Security Number (or please type NA if not applicable)
*
Your answer
Father's date of birth (necessary for insurance billing purposes)
*
Your answer
Marital Status
*
Married
Divorced
Single
Other:
Home Address (Street, City, State, Zip Code)
*
Your answer
Cell Phone Number (Best number to be reached before, during, and after appointments)
*
Your answer
Home Phone Number (or leave blank if none)
Your answer
Email
*
Your answer
In case of emergency and parent/guardian unavailable, call (First and last name)
*
Your answer
Emergency Contact Phone Number
*
Your answer
Whom may we thank for referring you to our office?
Your answer
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