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New Patient Form for Kids

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

Please use this form if your dependent is 18 years old or younger.
First
MI
Last

Responsible Party Information

First
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