Child Verification Form

Fill the form and submit it online or Click Here to download PDF

Child Registration Form

Today's Date:

Medical history

Has your child experienced any of the following?

Dental history

Do you have a dental related concern?

Is you child experiencing any of the following?

Responsible Party Information

Individuals to whom information may be given regarding your dental records and issues:


The signature affixed below authorizes examination and treatment by Dr. James E. McIlwain, Dr. Leigh Ann McIllwain, and/or Dr. Michael F. McIlwain and thier staff, and further, use of those procedures, which in the judgement of the doctor are necessary during the delivery of dental care.

I understand that McIlwain Family Dentistry is not a contracted provided for my insurance company, and that MFD will be filing to my insurance company as a courtesy and expect their payment in 30 days. I recognize that it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by the insurance company.

I hereby assign all dental and/or surgical benefits to which I am entitled, including private insurance and other health plans to: McIlwain Family Dentistry, Inc. This assignment will remain in effecct until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assigns to release all information necessary to secure the payment.

Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. The notice contains a Patients Rights section describing your rights under the law. You have the right to review our notice before signing this Consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment, or health care operation. We are not required to agree to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. How ever, such a revocation shall not affect any disclosures we have already made in regards to your prior Consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

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