New Patient Information

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Child's Information Child's Name:
Sex: Male Female
Age:
Home Address:
City:
State: Zip:
Phone:
Nickname:
Birthdate:
School:
Grade:
Do you already have an appointment?
Yes No
If Yes, Date:
If Yes, Time:
If No, Please call to Arrange an appointment.

PARENT OR GUARDIAN INFORMATION (MOTHER OR GUARDIAN) Name:
Relationship:
Address: (if different than child's)

City:
State: Zip:
Phone:
Birth Date:
Cell Phone:
Employer:
Occupation:
Work Phone:

PARENT OR GUARDIAN INFORMATION (FATHER OR GUARDIAN) Name:
Relationship:
Address:(if different than child's)

City:
State: Zip:
Phone:
Birth Date:
Cell Phone:
Employer:
Occupation:
Work Phone:

PRIMARY DENTAL INSURANCE Insured's Name:
Relationship:
Birth Date:
Employer:
Insurance Company:
Group#:
ID#:
Ins. Co. Address:
City:
State: Zip:

FINANCIAL ARRANGEMENTS

For your convenience we offer the following methods of payment. Please check the option you prefer. Payment in full is due at each appointment.

Cash
Personal Check
Visa
MasterCard

I authorize the dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my dependent's behalf. I agree to be responsible for all fees incurred in attempting to collect these fees.

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Children's Dental Health Associates | 519 Baltimore Pike | Chadds Ford, PA 19317 | More Locations