New Patient Form for Children and Teens

Step 1 of 7

Patient Information

Patient Name*

Gender

Male

Female

Date of Birth (mm/dd/yyyy)

Social Security Number

Age

Home Address

City

State

Zipcode

Email Address*

Primary Phone Number

Phone Type

Home

Cell

Other

School

Grade

List any sports or extracurricular activities

Siblings (names and ages)

Emergency Contact Information

Emergency Contact Name (other than parents)

Relation to Child

Phone Number

Phone Type

Home

Cell

Other

Address

City

State

Zipcode

Please add the name(s) of the person(s) we are authorized to release appointment and medically-related information to:

Authorized Person's Name

Relation to Child

Would you like to add an additional authorized person?

Yes

Authorized Person's Name

Relation to Child

Insurance Information

Do you have insurance?*

Yes

Primary Insurance Information

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation to Child

Policy Holder's Social Security Number

Policy Holder's Birthdate

Employer

Work Phone Number

Copay (if known)

Deductible (if known)

Do you have secondary insurance?

Yes

Secondary Insurance Information

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation to Child

Policy Holder's Social Security Number

Policy Holder's Birthdate

Employer

Work Phone Number

Copay (if known)

Deductible (if known)

Authorization

Authorization*

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my reponsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party*

Today's Date*

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Orthodontist · Rockford & Grand Rapids, MI

Child/Teen Patient Registration

Patient Information

Parent/Guardian Information

Emergency Contact Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

Authorization

Customize Your New Patient Experience

Schedule Your Free Virtual OR In-Office Consultation Today

We're Here When You Need Us

Our phone lines are open 7 days a week
Grand Rapids Office 616-656-4155 - Rockford Office 616-951-3006

Get In Touch

Contact Us

Quick Links

Follow Us

Heinz Orthodontics proudly serves Rockford, Ada, Cedar Springs, Grand Rapids, Greenville and Sparta, MI. To contact us, call (616) 951-3006, email us, or follow us on social media:

© 2020 – 2023 Heinz Orthodontics. All rights reserved. Orthodontic website design by New Patient Group

Orthodontist · Rockford & Grand Rapids, MI

Child/Teen Patient Registration

Patient Information

Parent/Guardian Information

Emergency Contact Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

Authorization

Customize Your New Patient Experience

Schedule Your Free Virtual OR In-Office Consultation Today

We're Here When You Need Us

Our phone lines are open 7 days a week Grand Rapids Office 616-656-4155 - Rockford Office 616-951-3006

Get In Touch

Contact Us

Quick Links

Follow Us

Heinz Orthodontics proudly serves Rockford, Ada, Cedar Springs, Grand Rapids, Greenville and Sparta, MI. To contact us, call (616) 951-3006, email us, or follow us on social media:

© 2020 – 2023 Heinz Orthodontics. All rights reserved. Orthodontic website design by New Patient Group

Our phone lines are open 7 days a week
Grand Rapids Office 616-656-4155 - Rockford Office 616-951-3006