RICD NP Screening Form

1
Guardian Name* This field is required.
First Name
Last Name
2
Number of Children & Ages* This field is required.
# of Children
Age(s)
3
Town & State* This field is required.
Town, Zip Code
State
4
Insurance* This field is required.
Subscriber Name & DOB
Insurance Name/ State/ ID #/ Group #
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Area Code
Phone Number
7
Dental Concerns* This field is required.(i.e. child experiencing dental pain/discomfort, specialist referral [name of referring doctor & treatment needed*], first dental appointment, orthodontic consultation, etc.)
8
Orthodontic Treatment?* This field is required.Is your child in active orthodontic treatment? If yes, who is the orthodontist and when was the last visit?
9
Are you being Referred by Another Providers Office?* This field is required.If you're being referred to our practice for treatment, please include the referring doctor's name below.
10
How did you hear about us?
In-home Mailer
Social Media
Insurance
Practice Website
Internet
Family / Friend/ Coworker
Email
Other
11
Like Us On Facebook!
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