Please enable JavaScript in your browser to complete this form.Welcome,Our goal is to make your childâs visit both pleasant and educational. We base our practice on preventive care. Together, we can help your child have a beautiful and healthy smile that can last a lifetime.ABOUT YOUR CHILD NameNicknameBirth DateGenderMaleFemaleSocial Security NumberHome AddressHome PhoneABOUT YOU Your NameMarital StatusSingleMarriedDivorcedWidowedRelationship to ChildYour Social Security NumberYour Home Address (if different from child)Home PhoneCell PhoneEmployerOccupationWork PhoneWhom may we thank for referring you to our office?ABOUT YOUR SPOUSE (If you are married, please complete this section) Your Spouse's NameTheir Cell PhoneTheir EmployerTheir OccupationTheir Work PhoneEMERGENCY INFORMATION (Please name someone other than spouse) NameRelationshipPhoneCell or Work PhoneDENTAL INSURANCE #1 Cardholder NameRelationship to ChildCardholder Birth DateSocial Security NumberYour EmployerYour Group NumberInsurance CompanyInsurance Company AddressInsurance Company PhoneDENTAL INSURANCE #2 Cardholder NameRelationship to ChildCardholder Birth DateSocial Security NumberEmployerGroup NumberInsurance CompanyInsurance Company AddressInsurance Company PhoneBy submitting this form you understand that the information you have given is correct.You authorize treatment of required dental services and release of information for insurance, appointment scheduling and confirmation. You understand that you are responsible for all costs of dental treatment and direct payment to Dr. Bobâs Family Dental.Submit
