Children's Dentistry of East Cobb

Child's Information

Child's First Name *

Child's Last Name *

Date of Birth *

Gender

2nd Child (if applicable)

Child's First Name

Child's Last Name

Date of Birth

Gender

Parent / Guardian Information

Mother's Information

Relationship

First Name *

Last Name *

Birthdate

Street Address

City

State

Zip

Employer

Mobile Phone *

Work Phone

Occupation

Father's Information

Relationship

First Name

Last Name

Mobile Phone

Insurance Information

We do not have dental insurance

Primary Insurance

Insurance Company

Insurance Phone

Insured Name

Insured ID / Employee #

Employer

Group #

Secondary Insurance (if applicable)

Insurance Company

Insured Name

Insured ID

Group #

It's our policy to discuss our fees and financial arrangement openly and honestly with you. Regardless of whether you have dental insurance or not, you are responsible for the full financial cost of dental treatment. Payment is expected as dental services are performed unless financial arrangements have been previously made with our office.

Email Address *

Signed By *

Date

Your child's smile starts here

Schedule a free consultation today and see why families across East Cobb trust us with their children's dental care.

Book Free Consultation (770) 973-7687

Patient Information Form