East Cobb Dental
Patient Information
Child's First Name
Child's Last Name
Child's DOB
Child's Gender: Select One Male Female
2nd Child Data
Mother's Information
Relationship
Mother
Guardian
Stepmother
First Name
Last Name
Mother's Birthdate
Mother's SSN
Street Address
Street Address Line 2
City
State
Zip
Mother's Employer
Mother's Driver's License #
Mother's Home Phone
Mother's Work Phone
Mother's Mobile Phone
Mother's Occupation
Father's Information
Father
Stepfather
Father's Birthdate
Father's SSN
Father's Employer
Father's Driver's License #
Father's Home Phone
Father's Work Phone
Father's Mobile Phone
Father's Occupation
Referred to our office by
Check the box if you or your child don't have insurance
PRIMARY
Primary Insurance Co
Primary Ins. Phone #
Primary Ins. Co. Address
Primary Insured Name
Primary Insured ID/Employee
Employer
Group #
SECONDARY
Secondary Insurance Co
Secondary Ins. Phone #
Secondary Ins. Co. Address
Secondary Insured Name
Secondary Insured ID/Employee
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. Every effort will be made to estimate to the best of our ability the total cost of dental treatment. Please be aware that treatment rendered may vary from the estimated treatment plan due to the continual progression of dental decay with time. Payment is expected as dental services are performed unless financial arrangements have been previously made with our office.
E-mail Address
Signed By
Date
