RiteBite | Patient Information Form

Are you completing this form on behalf of a dependent child?*
Family Information

The following is requested so that we can communicate properly with the people involved in your child’s treatment.
Parent are...*
Child lives with...*
Parent #1 — Details
Parent #1 — Name*

First NameLast Name
Parent #1 — Address*
Street
Parent #1 — City*
Parent #1 — Postal Code*
Parent #1 — Email*
Parent #1 — Mobile Phone*
Parent #1 — Home Phone
Parent #1 — Date Of Birth*

MonthDayYear
Would you like to add Parent #2 details?*
Parent #2 — Details
Parent #2 — Name*

First NameLast Name
Parent #2 — Address*
Street
Parent #2 — City*
Parent #2 — Postal Code
Parent #2 — Email*
Parent #2 — Mobile Phone*
.
Parent #2 — Home Phone
Parent #2 — Date Of Birth*

MonthDayYear
Are there any other adults we should know about?*
Other Adult #1 — Name

First NameLast Name
Other Adult #1 — Relationship To Patient
Other Adult #1 — Mobile Phone
.
Other Adult #1 — Home Phone
Other Adult #2 — Name

First NameLast Name
Other Adult #2 — Relationship To Patient
Other Adult #2 — Mobile Phone
.
Other Adult #2 — Home Phone
.

Insurance Information

The following is requested so that we can assist in determining any qualifying insurance coverage for Orthodontics.
Insurance Company
Employee Name
Date of Birth
Group #
Certificate #
Is there another adults in the family that has insurance coverage?*
Insurance Company
Employee Name
Date of Birth
Group #
Certificate ID/#
Treaty #

How Did You Hear About Our Office?
Please tell us how you arrived at our office?*

Family DentistGoogle SearchSocial Media Post (ie Facebook, Instagram, Tik Tok)Invisalign WebsiteOther AdvertisementA Family Member Is Being/Has Been Treated HereA Friend How Had/Has Treatment Here RecommendedOther
Please specify name*
We love to thank our patients for their referrals!

Signature of Patient/Responsible Party
RELEASE OF INFORMATION: I hereby give RiteBite permission to release information concerning my (child's) dental and/or orthodontic health to my family physician, dentist, any other dentist specialist or my insurance company as is deemed necessary, and for teaching as well as internal office purposes. This information includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.
Signature of Patient or Responsible Party*

Clear
Today's Date*

MonthDayYear
Date

PLEASE SUBMIT THE FORM BY CLICKING THE BUTTON BELOW.

Thank you for choosing RiteBite. We can't wait to start you on your smile journey!
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Patient Information Form