Child Patient Information Form

Welcome to Harbour Pointe Orthodontics! Please complete all information prior to your child’s first visit with us. Be assured that your private information will remain confidential as described in our Privacy Notice. For questions or assistance in completing this form, please contact us at (425) 348-5060.

  • Our services are billed to the patient or their responsible party. Your dental insurance is a contract between the insured family member/employee and their insurance company. We will gladly assist you in submitting claims by filling out paperwork, but you are ultimately responsible for fees incurred even if your insurance changes. Please have your insurance card and social security number if you have orthodontic coverage and would like us to inquire about your benefits.
  • For patients age 16 and under only.