Patient First Name

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Patient Last Name

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Child’s Legal Name

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Child’s Date of Birth

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Street

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City

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Zip Code

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Birth Gender

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School:

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Grade:

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Teacher:

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Parent/Guardian Name:

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Phone Number:

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Parent/Guardian email address

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Parent/Guardian’s Date of Birth

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Medical Conditions:

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Medications:

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Allergies

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Dental Issues:

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Contact Name

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Phone Number

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Relationship

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Primary Care Physician

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Primary Dental Provider

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I would like more information on health insurance for my child:

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I give my permission for my child’s photo to be taken for promotional use:

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I have medical insurance for my child:

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What is the name of your child’s primary medical insurance company?

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ID Number:

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Date of child’s last dental visit:

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I would like my child to be a member of the kids club:

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Name of Dental Insurance Company:

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ID Number

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Group Number

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Name that appears on dental insurance card:

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Insured Parent’s Date of Birth

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Address:

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Social Security number of the parent on the dental insurance card:

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Telephone number shown on dental insurance card:

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Insured parent/guardian employer name

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Relationship to child;

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How many live in your household, including yourself?

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Total Household Income

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Yes, I give permission for my child to participate in the Cornerstone Care dental program during the current school term. I understand that my child will receive a dental exam, dental cleaning, fluoride, x-rays, and sealants if recommended by the dentist.

Signature of Parent/Guardian

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Date

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I give my permission to the staff of Cornerstone Care to release information regarding my child’s medical and dental care, including my medical or dental condition, test results, appointment dates/times to the child’s School/School District AND I give my permission to the staff of the School/School District to release information regarding my child’s me.dical and dental care, including my medical or dental condition, test results, appointment dates/times to Cornerstone Care.

Signature of Parent/Guardian

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Date

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Telehealth Appointments are now available!

Cornerstone Care Mobile Dental Program

Home Address

*IMPORTANT: List all medical conditions, medications, & allergies.

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have received that Notice of Privacy Practices for Cornerstone Care.