PROVO PEDIATRIC DENTAL 2025

1. Click ‘Get Form’ to open the PROVO PEDIATRIC DENTAL document in the editor.
2. Begin by filling out the PATIENT INFORMATION section. Enter your child's nickname, name, gender, age, and birth date. Don't forget to include hobbies and contact details for the person financially responsible.
3. Proceed to the PERSONAL INFORMATION section. Input both parents' or guardians' names, addresses, employers, social security numbers, and phone numbers. Indicate if dental insurance is carried for your child.
4. In the INSURANCE INFORMATION section, provide details about your insurance company including its name, phone number, address, group number, policy number, and whether it is primary or secondary coverage.
5. Complete the DENTAL HISTORY section by noting the date of your child's last dental visit and any relevant dental habits or experiences.
6. Fill out the MEDICAL HISTORY section with information about your child's physician and any medications they are currently taking. Check any relevant medical history boxes.
7. For EMERGENCY CONTACT details, enter a name and relationship of someone who can be contacted in case of an emergency.
8. Finally, review the AUTHORIZATION section carefully before signing to confirm that all information provided is accurate.

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