PATIENT UPDATE FORM

PATIENT INFORMATION

CHILD/MINOR INFORMATION (CONFIDENTIAL)
Welcome!

Thank you for choosing Wabash Valley Children's Dentistry. It is our goal to provide your child with the best possible dental care. To help us meet all of your possible dental health needs, please fill out this form. If you have any questions, please ask any of our staff.
Name of Minor/Child
Date

MonthDayYear
Date
Gender

MaleFemale
Birth Date

MonthDayYear
Date
Social Security #
Address

Minor/Child Mailing Address

Street Address Line 2

CityState

Zip
Name of School
School Phone
Full Names and Ages of Patient's Siblings

WVCD AUTHORIZATION FOR FAMILY COMMUNICATION
I authorize Wabash Valley Children's Dentistry, L.L.C. to release the following information about my minor/child's health care (please initial all that apply):
Any and all information.Information necessary to schedule, confirm, cancel or reschedule an appointmentInformation about test resultsInformation about prescriptionsInformation about my bills or accountI grant permission to this individual to bring my child to his/her appointmentOther
Name
Relationship to Patient/Guardian
I choose not to authorize any individuals at this time: (Initial)
(Initial)
I understand that this authorization is valid until revoked by the patient, or the patient's parent/guardian.
Date

MonthDayYear
Date
Printed Name
Signature

Clear

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Notice of privacy Practices of the office of the wabash Valley Children's Dentistry, L.L.C
Date

MonthDayYear
Date
Patient/Guardian's Name
Patient or Legal Guardian Signature

Clear
Should be Empty:

PATIENT INFORMATION