Patient Registration Family New Patient Intake Form FamilyNew Patient Intake FormPatient Name* First Last Preferred name Patient Date of Birth* MM DD YYYYChild's Name First Last Preferred name Child's Date of Birth MM DD YYYYChild's Name First Last Preferred name Child's Date of Birth MM DD YYYYAddress* Street Address City State Zipcode Home Phone Email* Cell Phone*Emergency ContactEmergency Contact* Emergency Contact Name Emergency Contact Phone Number Emergency Contact Relationship to patient/s Whom may we thank for referring you?Insurance CardAccepted file types: jpg, gif, png, pdf.Please upload your dental insurance CardDental Insurance Company (If unable to upload image)Subscriber NameSubscriber Date of Birth MM DD YYYY Subscriber ID# Group# Assignment and Release:* I assign directly to Dr. Reddish all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Date* Please make sure to click SUBMIT before advancing to the next page Pages: 1 2 3 4 5 6