Child Information Form
Child's Name: ________________________________
Nickname: _______________________________
Birth Date: _______________ [ ] Male [ ] Female
Social Security # ___________________________
Home Address: ____________________________
________________________________________
Home Phone # ____________________________
About You
Your Name: ______________________________
Marital Status: [ ] S [ ] M [ ] D [ ] W
Relationship to child: _______________________
Your Social Security # ______________________
Your Home Address: (if different from child)
________________________________________
________________________________________
Home Phone # ____________________________
Cell Phone # ______________________________
Employer: _______________________________
Work Phone # ___________________Ext_______
Whom may we thank for referring you to our office?
__________________________________
About Your Spouse
(If you are married, please complete this section)
Your Spouse’s Name: _______________________
Their Cell Phone # _________________________
Their Employer: ___________________________
Their Work Phone # ________________________
Emergency Information
(Please name someone other than spouse)
Name: _____________________________________
Relationship: ________________________________
Home Phone # ______________________________
Cell or Work Phone # _________________________
Dental Insurance #1
Cardholder Name: ___________________________
Relationship to child: [ ] Parent [ ] Other___________
Cardholder Birth date: _________________________
Social Security # ____________________________
Employer: _________________________________
Group # ____________________________________
Insurance Co.: _______________________________
Ins. Address: ________________________________
___________________________________________
Dental Insurance #2
Cardholder Name: ____________________________
Relationship to child: [ ] Parent [ ] Other____________
Cardholder Birth date: _________________________
Social Security # _____________________________
Employer: _________________________________
Group # ___________________________________
Insurance Co.: ______________________________
Ins. Address: _______________________________
__________________________________________
I understand that the information I have given is correct. I authorize treatment of required dental services and release of information for
insurance, appointment scheduling and confirmation. I understand that I am responsible for all costs of dental treatment and direct
payment to Drs. Slovick & Sujack.
_______________________________________________________________________
(signed) (date)