Patient Registration Form - Young Kidz Dental

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Step 1 of 8

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Welcome! Please fill out the patient registration below, and you'll be redirected to the 'Book an Appointment' page when complete.
We are pleased to welcome you and your child to our practice. Our goal is to educate, motivate, and promote good oral health that will last a lifetime. Please take a few minutes to fill out this form completely. Please mark “SAME” or “N/A” where appropriate
1. Tell Us About Your Child
Child’s Name:*
Nickname:
Gender:
- Male
- Female
Home Address:
Street Address City State / Province / Region ZIP / Postal Code Country
Phone:
SSN:
Child’s Birthdate:
MM slash DD slash YYYY
Age:
School:
Grade:
Special interests/ Pets:

2. Person Accompanying The Child
Name*
First Last
Relation to child:
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone:
Work #:
Cell #:
Are you the legal guardian of this child?
- Yes
- No
Are you the person responsible for the account?
- Yes
- No
If no, please name the legal guardian / responsible party:
How did you hear about us?
*Whom may we thank for referring you:

8. Insurance Information
Policy Holder’s Name:
Birthdate:
MM slash DD slash YYYY
SS#:
Insurance Name:
Ins. Phone:
Ins. Address:
Street Address City State / Province / Region ZIP / Postal Code Country
Policy ID#:
Group #:
Policy Holder’s Employer:
Secondary Insurance ( if applicable)
Policy Holder’s Name:
Birthdate:
MM slash DD slash YYYY
SS#:
Insurance Name:
Ins. Phone:
Ins. Address:
Street Address City State / Province / Region ZIP / Postal Code Country
Policy ID#:
Group #:
Policy Holder’s Employer:

9. Authorization and Release
I agree to be responsible for payment of all services rendered on behalf of my dependent. I understand that my dental insurance plan is designed to only share in my dental costs, usually covering 50 to 80% of the total dental bill. I understand the amount of dental benefits I receive is determined by my employer or my insurance company, not by us. I understand some dental services may not be covered by my insurance plan. I understand it is my responsibility to review my insurance policy and to understand my specific dental benefits. In the event my insurance company has not paid their portion within 60 days, the balance of the bill will become my responsibility. I have read and agree to the payment information and release listed above.
I authorize Young Kidz Dental to submit insurance claims on my behalf.
I agree to be responsible for payment of all services rendered on behalf of my dependent. I understand that my dental insurance plan is designed to only share in my dental costs, usually covering 50 to 80% of the total dental bill. I understand the amount of dental benefits I receive is determined by my employer or my insurance company, not by us. I understand some dental services may not be covered by my insurance plan. I understand it is my responsibility to review my insurance policy and to understand my specific dental benefits. In the event my insurance company has not paid their portion within 60 days, the balance of the bill will become my responsibility. I have read and agree to the payment information and release listed above.
Signature of parent or guardian
Date
MM slash DD slash YYYY
10. HIPAA Consent Agreement (Privacy Act)
* you may refuse to sign this agreement* Please view a copy of our policy on our website at https://youngkidzdental.com/wp-content/uploads/2020/06/HIPAA-Privacy-Notice.pdf
I give consent for the Use and Disclosure of Health Information of myself or my dependant for the purposes of Treatment, Payment, or Communication between other healthcare professionals.
I understand and have been provided with a copy of this office’s Notice of Privacy Practices that provides a more complete description of health information uses and disclosures.
I understand that I have the right to review a copy of this office’s Notice of Privacy Practices prior to signing this condensed form.
Please Print Name
Signature of parent or guardian
Date
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Sam D.

Mar 19, 2020

by Sam D. on Young Kidz Dental

Dr. Young and his staff are absolutely amazing! I have a child with special needs and they are so fantastic with making sure everything is just the way he needs it. Plus they are so so patient and sweet with my toddler. I highly recommend this dental practice. My kids love going because of how great they are!

SUPER C.

by SUPER C. on Young Kidz Dental

I have been taking my kids to Dr.Young for about 10 years now and he is so amazing with all 4 of my kids, the dental hygienist is super nice and patient with my 4 year old twins and my kids always get excited when it’s time to go see Dr.Young!

Arriana S.

by Arriana S. on Young Kidz Dental

It’s all about the phone call returned within a day, the willingness to work with schedule mishaps, cancellations and re-scheduling appointments. The kind voices of staff while on a phone call with them. The excellent care of all the staff from the dentist, to the hygienest , assistant and office support.

Jacob M.

by Jacob M. on Young Kidz Dental

Young Kidz Dental is an excellent pediatric dental clinic. Everyone from the front office staff to the dental assistants to the doctor are top notch. We have been very happy with our experiences here.

Annie Mortland C.

by Annie Mortland C. on Young Kidz Dental

Thanks so much to Young Kidz Dental for the excellent work with my boys today. You even got my cranky 3-year-old to open up and get a thorough cleaning (I wasn’t optimistic!). We are very grateful for your staff for the cheerful and supportive care.

Step 1 of 8

1. Tell Us About Your Child

2. Person Accompanying The Child

3. Parent’s Information

Mother

Father

4. Child’s Dental History

5. Child’s Medical History

6. Consent for Treatment

7. Payment Information

8. Insurance Information

9. Authorization and Release

10. HIPAA Consent Agreement (Privacy Act)

Step 1 of 8

1. Tell Us About Your Child

2. Person Accompanying The Child

3. Parent’s Information

Mother

Father

4. Child’s Dental History

5. Child’s Medical History

6. Consent for Treatment

7. Payment Information

8. Insurance Information

9. Authorization and Release

10. HIPAA Consent Agreement (Privacy Act)

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