Dover Kids Teeth

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Fields marked with * denotes mandatory

YOUR CHILD/CHILDREN

First Name *

Middle Initial

Last Name *

Suffix

Date of Birth *

Gender at Birth *

Yes

Do you have Dental Insurance? *

DENTAL INSURANCE INFORMATION

Name of Insured *

Relationship *

Date of Birth *

Name of Employer *

Dental Insurance Company *

Group #

Policy/ID # *

Insurance Address

City

State

Zip Code

Insurance Phone #

Insurance Card FRONT File Format: JPEG, PDF and PNG. Max. Size: 10 MB

Insurance Card BACK File Format: JPEG, PDF and PNG. Max. Size: 10 MB

Yes

Do you have additional dental insurance? *

Name of Insured *

Relationship *

Date of Birth *

Name of Employer *

Dental Insurance Company *

Group #

Policy/ID # *

Insurance Address

City

State

Zip Code

Insurance Phone #

Insurance Card FRONT File Format: JPEG, PDF and PNG. Max. Size: 10 MB

Insurance Card BACK File Format: JPEG, PDF and PNG. Max. Size: 10 MB

I accept that all payments are due when services are provided. *

How did you hear about us?

Friend

Dr. Referral

School

Social Media

Other

Signature of Parent/Legal Guardian *

Relationship *

Date *

* By completing this form online, you consent that you are electronically signing it.

New Patient Registration

YOUR CHILD/CHILDREN

PARENT INFORMATION

DENTAL INSURANCE INFORMATION

Monday - Thursday	8:00 AM – 5:00 PM
Friday - Sunday	Closed