Child Information Form

Welcome,

Our goal is to make your child’s 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


ABOUT YOU


ABOUT YOUR SPOUSE

(If you are married, please complete this section) 


EMERGENCY INFORMATION

(Please name someone other than spouse) 


DENTAL INSURANCE #1


DENTAL INSURANCE #2



By 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. Bob’s Family Dental.