Personal and Insurance Information

Personal and Insurance Information

Great Lakes Pediatric Dentistry
PATIENT INFORMATION
Child's Legal Name (First Last)
Preferred name:
Child's Social Security Number:
Birth Sex

MaleFemale
Current Gender Identity:
Child's Date of Birth

MonthDayYear
Date
Age:
Grade:
School:
Child's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
WHO IS ACCOMPANYING YOUR CHILD TODAY?
Name:
Relationship to the child:
Who can we thank for referring you?
Parents Marital Status:

MarriedSingleDivorcedWidowedSeparated
Other siblings seen by us?

YesNo
Please select any that apply and explain:

The child is in a foster homeThe child is adoptedI DO NOT have legal custody of the childParent's are divorced (Please explain custody and living arrangements)
Explain:
PARENTS INFORMATION (MOTHER)
Mother:

Biological MotherStepmotherAdopted MotherGuardianOther
Full Name (First then Last):
Social Security Number:
Cell Phone Number
Please enter a valid phone number.
Can we text you?

NoYes
Email
example@example.com
Profession:
example@example.com
PARENTS INFORMATION (FATHER)
Mother:

Biological FatherStepfatherAdopted FatherGuardianOther
Full Name (First then Last):
Social Security Number:
Cell Phone Number
Please enter a valid phone number.
Can we text you?

NoYes
Email
example@example.com
Profession:
PERSON RESPONSIBLE FOR ACCOUNT
Name:
Relationship to patient:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
Social Security Number:
Driver's License Number:
PRIMARY DENTAL INSURANCE COMPANY:
Name:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY DENTAL INSURANCE INSURED PERSON'S INFORMATION:
Name

First NameLast Name
Social Security Number:
Relationship to Patient:
Birthdate:

MonthDayYear
Date
Employer:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SECONDARY DENTAL INSURANCE
SECONDARY DENTAL INSURANCE COMPANY:

IF APPLICABLE
Name:
Group#: (Plan, Local, or Policy#):
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECONDARY DENTAL INSURANCE INSURED PERSON'S INFORMATION:

IF APPLICABLE
Name

First NameLast Name
Social Security Number:
Relationship to Patient:
Birthdate:

MonthDayYear
Date
Employer:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

WHO IS RESPONSIBLE FOR MAKING APPOINTMENTS?
Name

First NameLast Name
Relationship to Patient:
Phone Number
Please enter a valid phone number.
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my child’s medical status. I authorize the dental stay to perform the necessary dental services my child may need. As a parent or guardian who accompanies the child, I am responsible for payment at time of services unless prior arrangements have been approved.
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Personal and Insurance Information

PATIENT INFORMATION

WHO IS ACCOMPANYING YOUR CHILD TODAY?

PARENTS INFORMATION (MOTHER)

PARENTS INFORMATION (FATHER)

PERSON RESPONSIBLE FOR ACCOUNT

PRIMARY DENTAL INSURANCE COMPANY:

PRIMARY DENTAL INSURANCE INSURED PERSON'S INFORMATION:

SECONDARY DENTAL INSURANCE COMPANY:

SECONDARY DENTAL INSURANCE INSURED PERSON'S INFORMATION:

WHO IS RESPONSIBLE FOR MAKING APPOINTMENTS?