Patient Registration — Speedway Pediatric Dentistry

Patient Registration Form

Please complete the following form to help us understand how we can help to you.

First (e.g. insurance?

Parent/Guardian Information - First and Last Name

First

Last

Parent/Guardian Information - Date of Birth

Contact Information - Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information - Phone Number

How many children do you have?

Reason for Appointment (e.g. new patient, referral, existing patient, etc.)

Does the patient have primary insurance?

Does the patient have secondary or state insurance?

Additional Comments ( Does your child require any special accommodations, do they have any special healthcare needs, etc.)?