New Patient form for Dr. Winder
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. Our practice is based on preventive care. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.

1. Tell us about your child
Today's Date: ____________________________
Child's Name: ____________________________
Nickname:_______________________________
Circle one: Male  /  Female    Child's Age:_____
Child's Birthdate___/___/_______
S.S.#_____-______-______
School:_____________________ Grade:______
Phone Number:___________________________
Child's Home Address
________________________________________
________________________________________

5. Primary Dental Insurance
Insurance Co. Name:________________________
Insurance Co. Address:______________________
__________________________________________
Insurance Co. Phone #_______________________
Group # (Plan, Local or Policy #)
__________________________________________
Insured's Name:_____________________________
Relationship to Parent:_______________________
Insured's Birthday:___ / ___ / ______
Insured's Employer: _________________________
Orthodontic Coverage (circle one): Yes / No

2. Who is accompanying your child today?
Name:___________________________________
Relationship:______________________________
Do you have legal custody of this child? Yes / No
Who may we thank for referring you?
_________________________________________
Previous Dentist: __________________________
Present Dentist:___________________________
Last visit date:_____________________________
Other family members seen by us:_____________
_________________________________________
Parent's marital status (circle one):
Single - Widowed - Separated - Married - Divorced

6. Secondary Dental Insurance
Insurance Co. Name:________________________
Insurance Co. Address:______________________
__________________________________________
Insurance Co. Phone #_______________________
Group # (Plan, Local or Policy #)
__________________________________________
Insured's Name:_____________________________
Relationship to Parent:_______________________
Insured's Birthday:___ / ___ / ______
Insured's Employer: _________________________
Orthodontic Coverage (circle one): Yes / No

3.
Mother's information:
(circle if: step mother or guardian)
Name:___________________________________
Work #:______________Home#:______________
Employer:________________________________
S.S.#_____-______-______
Father's Information:
(circle if: step father or guardian)
Name:___________________________________
Work #:______________Home#:______________
Employer:________________________________
S.S.#_____-______-______

7. Relative we can call if needed
Name:____________________________________
Work #:______________Home#:_______________
Relationship:_______________________________

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services that my child may need.
___________________________________________
Signature of parent or guardian                  Date
4. Person responsible for account
Name:___________________________________
Relation:_________________________________
Billing Address:____________________________
_________________________________________
Work #:______________Home#:______________
Employer:________________________________
S.S.#_____-______-______

OFFICE USE ONLY
I verbally reviewed the medical/dental information above with the parent/guardian & patient named herein.
Initials:________________ Date:_________________