Personal Intake Form

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.

Who can bring your child(ren) to their appointment?*
Please list below any individual that can bring your child(ren) to their appointments. By listing their name you are also consenting to give this individual(s) permission to receive information, the right to sign the medical history and consent to routine dental treatment.
Name
First Last
Name
First Last
Name
First Last
Name
First Last
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 Ashby Park Pediatric Insurance and Office Policies.
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