Welcome to our practice!

We strive to make each of your child's visits pleasant and comfortable. Please complete the following information:

Child's Name   Nickname

Birth Date   Age       Social Security #       Sex   

School   Grade

Child's Address

City   State   Zip   Phone #

Responsible Party

Name   Relationship

Address

City   State   Zip   Email

Social Security #   Driver's License #

Who is responsible for making appointments?

Name

Home Phone   Cell Phone   Work Phone

Best time to call:   Time   Days

Mother

     

Name

Home Phone   Cell Phone   Work Phone

Email

Employer   Occupation

Social Security #   Driver's License #

Marital Status:        

Father

     

Name

Home Phone   Cell Phone   Work Phone

Email

Employer   Occupation

Social Security #   Driver's License #

Marital Status:        

Primary Insurance

Name of Insured   Relationship

Birth Date   Social Security #

Employer   Date Employed

Occupation

Insurance Company

Group #   Employee #

Insurance Co. Address

City   State   Zip

Insurance Phone#

Deductible   Copay

Amount already used   Max annual benefit

Additional Insurance

Name of Insured   Relationship

Birth Date   Social Security #

Employer   Date Employed

Occupation

Insurance Company

Group #   Employee #

Insurance Co. Address

City   State   Zip

Insurance Phone#

Deductible   Copay

Amount already used   Max annual benefit

Financial Arrangements

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment.