Child Adolescent Form - Amazing Smiles Orthodontics

PERSON RESPONSIBLE FOR ACCOUNT:
Name
Birth Date
MM slash DD slash YYYY
Relation to patient
- Employer
- DL#
- Work Phone
- Home Phone
Social Security #
Current Address
Street Address Address Line 2 City State ZIP Code
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
WHOME MAY WE THANK FOR REFERRING YOU OR HOW DID YOU HEAR ABOUT US?

- Insurance Co. Name
- Group # (Plan, Local or Policy #)
Insurance Co. Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Co. Phone #:
Policy Owner's Name
First Last
Relation to Patient:
Policy Owner's Social Security #
Policy Owner's Employer:
Date of Birth:
MM slash DD slash YYYY
Employer's Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

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 this office of any changes in the medical status of the patient named herein.
- Signature
- Today's Date
  MM slash DD slash YYYY