Child New Patient Form

Please complete this form. If you have questions, give us a call. We are happy to help!

Child's Personal Information
Name*
First Middle Last
Nickname
Gender*
- Male
- Female
Patient Birthday*
MEDICAID / Insurance ID #*
SSN (LAST 4 DIGITS)*
Address*
Street Address Address Line 2 City State ZIP Code
Insurance Information
Medicaid patients: skip this section unless you have 2 dental insurance plans.
Policy Holder Name*
First Last
Policy Holder Birthday*
Employer*
Policy Holder SSN (LAST 4 DIGITS)*
ID #*
Group #*
Insurance Phone Number*
Medical Information
Insurance Company
Pediatrician's Name
Is your child pregnant or nursing?*
- Yes
- No
Please list any medical conditions your child has:
Please list any medications your child takes:
Please list any medicines your child is allergic to:
Adult Information
Do you have legal custody of this child?
- Yes
- No
Legal Guardian's Information
Name*
First Middle Last
Relation to Child
SSN (LAST 4 DIGITS)*
Cell Phone
Home Phone
Work Phone
Digital Signatures
I certify that I have provided complete and truthful information, knowing that providing incorrect or false information can be dangerous to my child’s health.*
I authorize the release of all necessary information to third party payors and/or health practitioners and request my insurance company to send payment directly to this office.*
I have been offered a copy of the Notice of Privacy Practices and agree to its terms.*
As the adult accompanying the child, I accept responsibility to pay today what insurance is not expected to cover.*
I understand that missed or broken appointments may prevent me from being able to schedule again.*
I have been fully informed and all of my questions have been answered. I give my informed consent to be bound by all terms of all policies associated with Jared Cox DDS PA.*
We will provide you with good faith estimates based upon the information your carried provides to us about your policy. Please be aware that insurance carriers never guarantee payment according to the percentages they advertise to you, and they adjust their payments according to the fine details contained within your individual contract. After we submit your claim, your insurance carrier will review it to determine how much it will pay for your dental services. If your carrier pays more than we estimated the overpayment will be used to reconcile any family account balances do. If there are no account balances due, we will issue you a refund after all pending insurance claims have been received.*
I understand that any insurance overpayment will be used to reconcile my family balance before a refund is issued to me.*
TFD estimates are good for 60 days after they are given. Please be aware that your insurance policy has a limited amount that your carrier will pay each coverage year for all your dental services. If you were seen or will be seen by another dentist in the current coverage year or if your treatment will require a referral to a specialist’s office, your coverage may be exceeded, and your estimated patient portion quoted on your estimate may be incorrect. Please be aware that TFD cannot attain accurate information from your insurance carrier about dental services provided by a previous dentist or specialist. If your carrier denies or downgrades your claim because your annual coverage limit has been exceeded or for any reason, your account with us will be adjusted according to the insurance downgrade and you will be responsible to pay the balance due in full within 30 business days. I understand that if my coverage is exceeded or if my claims are denied/downgraded that I will pay the balance in full.*
Comments
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Child New Patient Form

Child's Personal Information

Insurance Information

Medical Information

Adult Information

Legal Guardian's Information

Digital Signatures

We Are Open

Our Values

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