Name* First Last Birthdate Date Format: MM slash DD slash YYYY GenderMaleFemaleAddress* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*SchoolGradePerson Responsible for Account First Last Relationship to ChildChild Resides with: Mother Father Guardian Other If Other, provide the name of that person:Name of Mother/GuardianBirthdate of Mother/Guardian Date Format: MM slash DD slash YYYY PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code EmployerBusiness PhoneChild's Dental HistoryFormer DentistOffice PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of last dental visitHow often does your child brush?How often does your child floss?Please check all that apply to your child: Thumb/Finger Sucking Fingernail Biting Grinding Teeth Lip or Cheek Biting Jaw Difficulty Clicking and/or Pain Child's Health HistoryPlease check all that apply to your child: Allergies Anemia Asthma Cancer Diabetes Epilepsy Heart Murmur Hepatitis-Type HIV/AIDS Rheumatic Fever Scarlet Fever Tonsillitis Tuberculosis Other OtherPrimary Dental InsuranceEmployerWork PhoneEmployer AddressOccupationInsurance CompanyInsurance Company AddressSubscriber I.D. #Group #Insured Date of BirthAdditional InsuranceEmployerWork PhoneEmployer AddressOccupationInsurance CompanyInsurance Company AddressSubscriber I.D. #Group #Insured Date of BirthAuthorization I hereby authorize payment directly to Southern Kentucky Smiles / Dr. Casey Travelsted for all insurance benefits otherwise payable to me for services rendered. I’ll understand that I am financially responsible for all changes, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.PhoneThis field is for validation purposes and should be left unchanged.
