Patient Information (Child)


Patient:

    
    
    


Parent/Guardian Information


    

    
    

    
    



Insurance information




I, the undersigned, certify that I(or my dependent) have the insurance coverage stated and assign directly to Dr. Thomas W. Barron, D.M.D., PA all insurance benefits, if any, payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby authorize Thomas W. Barron, D.M.D., PA to release all information necessary to secure payment of benefits. I autorize the use of this signature on all insurance submissions.


DENTAL HISTORY


Please answer the following questions by circling yes or no. This information is for our office records only and
Will be kept confidential. A complete and thorough history is vital for a proper orthodontic evaluation.

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
information/comments

    

MEDICAL HISTORY



    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
information/comments