Child Patient Information
We need dental insurance information NOT your medical insurance information. They are different.
***We need your Dental Insurance information NOT your medical insurance information (they are different)***
Please take and attach a picture of your dental insurance card (if available).
Make sure the photo is in focus and not blurry.
Only fill out the following information if you ARE covered by a secondary dental insurance plan.
ONE parent is permitted to remain with each child during treatment (other than sedation appointments). Dr. Donna will discuss with you the terms and conditions for this privilege. Other guests/siblings must remain in the waiting room accompanied by an adult.
I have fully read and understand the above APPOINTMENT & CANCELLATION POLICIES and accept all provisions.
I hereby acknowledge that the information provided above is a true representation of my child's medical and dental history/condition.
In order to make your visit as prompt and as pleasant as possible, please provide the following information:
As guardian, I hereby give the following person(s) my permission to bring my child/children to Pediatric Dentistry of Winchester.