Dr. Thoa Nguyen 

Dentistry just for Kids

Specializing in infants, children, and adolescents

Today's Date: ______________________

Patient's Name: ________________________________________SSN:_________________ DOB: _________________

Father's Name:________________________________ Mother'sName:_______________________________________

Permanent Address: _______________________________________________ City: ____________________________  State: ________________________Zip_______________ Home Phone: ______________________________________ Work______________________________________ Phone:(Father/Mother)____________________________________

Cell Phone:______________________________ (Father/Mother)____________________________________________

Email: __________________________

Can we call you at work? Y N Whom may we thank for referring you to our office?____________________

Assignment and Release:

I, the undersigned certify that I (or my dependent) have insurance coverage with                                          and assign directly to Dr. Thoa Nguyen all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I hereby authorize the doctor to release all information necessary to secure the payment of benefits.  I authorize the use of this signature in all insurance submissions.

                                                                                   ___            ___________________                        

Responsible Party Signature                           Relationship                                               Date

Dental History: