Youth/Patient Name:
Grade:
Teacher/Building Name
Birth Date:
/
Month
/
Day
Year
Date
Gender
Male
Female
Email Address:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Zip Code
Home Phone Number/Cellphone number:
Email of parent or guardian
example@example.com
Race
White
Black/African American
Native Hawaiian
American Indian/Alaska Native
Asian
Other Pacific Islander
More than one race
Refuse to report
Are you Hispanic/Latino
Yes
No
Refuse to report
Is English you primary language
Yes
No
Are you or a family member a Migrant or Seasonal Farmworker?
Yes
No
Guardian name
Guardian Phone Number:
Guardian Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient:
Emergency Contact Name:
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to youth
Dental Insurance:
Medical Insurance:
Subscriber Name:
Insurance ID #:
Subscriber Birthdate:
/
Month
/
Day
Year
Date
Relationship to patient
Subscriber Employer:
Household Income
Frequency
Weekly
Biweekly
Monthly
Annual
How many people in the household does this income support?:
Total 'Gross Annual' Household Income from all Sources:
*Total Number of People in Household
Head of Household/Authorized Person Name:
Head of Household/Authorized Person Signature:
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List Allergies
Heart problems? (list type)
Asthma?
Yes
No
Diabetes?
Yes
No
Seizures?
Yes
No
Other Medical conditions/Medications?
Yes, I give permission to have my child receive dental treatment from GLBHC's Mobile Dental Program.
Yes, I give permission to have my child receive dental treatment from GLBHC's Mobile Dental Program.
No, I would not like my child to receive dental treatment from GLBHC's Mobile Dental Program.
Patient/Guardian Name:
Patient/Guardian Signature:
Clear
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