770-343-4702 Personal Intake Form Are you in the Office or at Home? Office Home Preferred Dentistry for Children Location Select Location Austell Douglasville Buford Woodstock Cumming Name of first Legal Guardian* First Last Name of second Legal Guardian First Last Mailing Address* Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific ZIP Code Mobile Phone Number:* Required for further electronic communications. Other Phone Number: Email Address Add child/children you’re completing this intake form for? I am the Legal Guardian for the children named below: Child Name: Date of Birth Actions There are no children. Add Child Who can bring your child(ren) to their appointment?* Select number of people None 1 2 3 4 Please read each statement and signify approval by checking the box beside it: I am certifying that the information listed is complete and accurate. I am the legal guardian of the children identified above. I read and understand the Photo Release Form I read and understand the Photo Release Form I consent I decline I have read and understand the Privacy Act Document. I will be responsible for any fees not covered by my insurance company and have read and understand Dentistry for Children Insurance and Office Polices. Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate: Name of Legal Guardian:* First Last Date:* MM slash DD slash YYYY Associations & Partners Pediatric Dentists in Georgia Dentists Services Parents What’s New Georgia Pediatric Dental Care Emergencies Patient Forms Special Offers Your First Visit Contact Dentistry for Children Georgia Careers Reviews Privacy Notice Subscribe to our newsletter Have an Emergency? Get Help Copyright 2021 | All rights reserved. Site by Trew Knowledge. Powered by WordPress VIP.