Winterville Dental, LLC
Phillip H. Durden, DMD, MAGD, FAACP • Brandon W. Whitworth, DMD • Chase M. Wootton, DMD • Robert T. Hardell, Jr., DMD 104 Moores Grove Road • Winterville, Georgia 30683 • Phone 706.742.7000
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 Male Female
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
Mother Stepmother Guardian
Email
Employer Occupation
Father
Father Stepfather Guardian
Marital Status: Single Married Divorced Separated Widowed
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
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.
Cash Personal Check MasterCard Visa I wish to discuss the office's payment policy.