New Patient Form Part 1 of 2: Legal Guardian/Insurance Info, Financial Policies, Appointment Policies, & HIPAA Consent (one per family please)
Please note, this form must be completed by a legal guardian. Please complete this form only once for your entire family.
Please list the full name of the person completing this form.
Please list the names and dates of birth for the children this form applies to.
Please confirm the person completing this form is the legal guardian of the above listed children.
Yes, I am the legal guardian of the above listed children.
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This form was created inside of West Metro Pediatric Dentistry.