LKN New Patient Child Form | Lake Norman Orthodontics

PERSONAL INFORMATION

Name: First

Middle

Last

Nickname:

Sex:

Age:

Date of birth:

School:

Grade:

Brothers/Sisters (Name and Age):

Dentist:

Physician:

Referred by:

Mother

Name:

Address:

City:

State:

ZIP:

Home Phone:

Mobile Phone:

Employedby:

Work Phone:

Policy Owner’s Birthdate:

SS#:

Marital Status:

Parent’s email address:

Father

Name:

Address:

(if different)

City:

State:

ZIP:

Home Phone:

Mobile Phone:

Employedby:

Work Phone:

Policy Owner’s Birthdate:

SS#:

Marital Status:

Parent’s email address:

Person Responsible For Account:

PRIMARY DENTAL INSURANCE ONLY

Ortho coverage?

If “Yes” complete below

Insurance Co. Name:

Insurance Co. Address:

City:

State:

ZIP:

Insurance Co. Phone #:

ID/Policy #:

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

SS#:

Policy Owner’s Employer:

SECONDARY DENTAL INSURANCE ONLY

Ortho coverage?

Insurance Co. Name:

Insurance Co. Address:

City:

State:

ZIP:

Insurance Co. Phone #:

ID/Policy #:

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

SS#:

Policy Owner’s Employer:

9615 Caldwell Commons Circle, Suite A

Cornelius, NC 28031

(P) 704.896.8452 (F) 704.896.8124

Child Information Form

Lake Norman

Orthodontics

PERSONAL INFORMATION

Mother

Father

(if different)

PRIMARY DENTAL INSURANCE ONLY

SECONDARY DENTAL INSURANCE ONLY

MEDICAL HISTORY

DENTAL HISTORY

PATIENT AUTHORIZATION – PLEASE SIGN BELOW