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New Patient Form for Kids
Complete Family & Aesthetic Dentistry Logo
204 E. Baseline Rd.
Lafayette, CO 80026
303-665-4000
www.DentistLafayette.com

Patient Information

First
MI
Last

Responsible Party Information

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MI
Last
Street Address
City
State
ZIP Code

Other Responsible Party Information

First
MI
Last

Insurance - Primary

Insurance - Secondary

Assignment and Release

I certify that my dependent has insurance coverage and assign directly to Complete Family & Aesthetic Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.
CONSENT: I consent to the diagnostic procedures, treatment, and photos by the dentist necessary for thorough, comprehensive dental care.
Complete Family & Aesthetic Dentistry
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