Adult Registration Form
We strive to make each of your child's visits pleasant and comfortable. Please fill out this form completely in ink.
Today's Date
/
Month
/
Day
Year
Date
Your Child
Child's Name
Sex
Age
Nickname
SSA/SIN
Birthdate
/
Month
/
Day
Year
School
Grade
Child's Home Address
Street Address
Street Address Line 2
City
State / Province
Zip/P.C.
Phone
Format: (000) 000-0000.
Responsible Party
Name
Relationship
Address
Email
example@example.com
City
State/Prov
Zip/P.C.
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
SSA/SIN
DL #
Who is Responsible for Making Appointments?
Parent or Guardian Information
Mother
Stepmother
Guardian
Name
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Employer
Occupation
SSA/SIN
DL #
Marital Status
Single
Married
Separated
Divorced
Widowed
Parent or Guardian Information
Father
Stepmother
Guardian
Name
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Work Phone
Format: (000) 000-0000.
Employer
Occupation
SSA/SIN
DL #
Marital Status
Single
Married
Separated
Divorced
Widowed
Primary Insurance
Insured's Name
Relationship
Birthdate
/
Month
/
Day
Year
Date
SS#/SIN
Employer
Date Employed
/
Month
/
Day
Year
Occupation
Insurance Co.
Group #
Employee #
ins. Co. Address
City
State/Prov.
Zip/P.C.
Deductible
Copay
Amount already used
Max annual benefit
Additional Insurance
insured's Name
Relationship
Birthdate
/
Month
/
Day
Year
Date
SS#/SIN
Employer
Date Employed
/
Month
/
Day
Year
Occupation
Insurance Co.
Group #
Employee #
ins. Co. Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State/Prov.
Zip/P.C.
Deductible
Copay
Amount already used
Max. annual benefit
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