Child Lives with: Both Parents Father Mother Other
Child/Children(s) Address if different from below:
Primary Billing Party: Father Mother
Father's Full name:
Marital Status: Married Single Divorced Widowed
Email Address: by providing your email address you are giving MooreKids Smile Pediatric Dentistry permission to contact you via email for appointment confirmation and notice for overdue appointments. You may opt out at any time
Dental Insurance Company (If applicable):
Social Security #:
Mother's Full name:
The Parent or Guardian who accompanies the child responsible for payment at the time of service, unless prior arrangements have been made.
In consideration of the professional services rendered to my child, I agree the responsibility of payment for such services.
In order to comply with most insurance companies, we ask that you sign below to keep your signature on file; I have reviewed the following treatment plan. I authorize release of any information regarding this claim.
I hereby authorize payment directly to the below-name dentist of the group insurance benefits otherwise payable to me.
I am also responsible for any remaining balance on my account not covered by my group insurance benefits.
169 Main Street,
Hamburg, New York 14075