Lily W. Eng, DDS

101 Lafayette Street, 9th Floor, New York, NY 10013

212-842-5300, 212-842-8042

Thank you for selecting our dental healthcare team! To help us meet all your dental needs, please read our office policy of parent / legal guardian carefully, and fill out this form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help.

Witness Initial:

*Child must be accompanied by a parent or legal guardian for the first visit, first injection in this office, and irreversible treatment. An authorized adult can accompany the child for all other visits.

** Your child will only be treated when accompanied by a Guardian/Parent or an authorized person listed on this form. Please provide information of individuals who are authorized to accompany the child to dental visits, consent for dental treatment and financial agreements. (Please Note: Authorized Guardian must be 18 years or older)

Child's Name:
Birth Date:
Social Security#:
Gender:


1st Parent's/Legal Guardian's Name:
Birth Date:
Home Phone:
Cell Phone:
Work Phone:
Ext:
Relationship to Child:
Social Security#:
Address:
E-mail:
Best Way to Contact You:


2nd Parent's/Legal Guardian's Name:
Birth Date:
Home Phone:
Cell Phone:
Work Phone:
Ext:
Relationship to Child:
Social Security#:
Address:
E-mail:
Best Way to Contact You:


Parent / Guardian with legal custody:
Person Responsible for the Account:


Assignment of Authorized Guardian

*Authorized Guardian information will be valid for all visits unless otherwise indicated.

1st Authorized Guardian's Name:
Relationship to Child:
Contact Phone#:
Birth Date:
2nd Authorized Guardian's Name:
Relationship to Child:
Contact Phone#:
Birth Date:


Signature of Parent/Legal Guardian

Use your mouse cursor or the tip of your finger to sign below

Date:
Relationship to patient:

Doctor's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: