New Patient Family Form2019-01-29T15:20:38+00:00

PATIENT INFORMATION

Patient Name
Date of Birth
Nickname (if any)
Gender
MF
MF
MF
MF
MF

 

Address   City   ST   Zip 
Home Phone   

 

Mother/Legal Guardian
 
Father/Legal Guardian
Name   Name
Employer   Employer
Work Phone   Work Phone
Cell Phone   Cell Phone
SS#   SS#
DOB   DOB

 

Parents Marital Status MarriedSingleWidowedSeparatedDivorced

 

Which cell phone number do you prefer for text message appointment reminders?
Mom's CellDad's CellOther
Please provide an email address for appointment reminders

 

How did you hear about our office?
InternetInsuranceDriving ByEventMailerDr. / PersonOther

 

EMERGENCY CONTACT (AFTER PARENTS)

In The Event Of An Emergency, Who Should We Contact?

 

Name  Relationship to Patient   Phone 

 

CONSENT FOR DENTAL TREATMENT

I request and authorize Dr. Lisa Ameer and her staff to perform cleanings, exams and place topical fluoride treatments on my child. I request and authorize dental x-rays to be taken on my child as considered necessary by Dr. Lisa Ameer to diagnose and/or treat my child’s dental needs. I acknowledge that I have been explained all the behavior management techniques that may be used with my child while experiencing dental treatment. I have been given the opportunity to discuss any questions that I may have.

I am permitted by law (by right as a natural parent, legal adoption, or court order) to provide consent for the dental treatment of this child.(Documentation may be requested from you regarding rights ofparental consent for the child)
YesNo

 

Parent/Guardian Printed name
Date