New Patient Forms

BOOK APPOINTMENT

When your child visits our office for the first time, we will need to complete and file the following forms:

* For your convenience, you may download, print and fill out this form, as it will be needed in your next appointment.

1. Medical History *

These are for current patients to update their medical information. Include any medical conditions, allergies and surgeries your child may have had. Please include your child’s information from their pediatric care provider and from their previous dentist if applicable.

Download Medical History Update Form (English)
Download Medical History Update Form (Spanish)

 

These are for new patients to provide their medical information. Include any medical conditions, allergies and surgeries your child may have had. Please include your child’s information from their pediatric care provider and from their previous dentist if applicable.

Download Pediatric Medical History Form (English)
Download Pediatric Medical History Form (Spanish)

2. HIPPA Forms *

These forms are related to the protection of your private information. These forms are provided at the office and you can sign them electronically. There are 2 forms.

Download HIPPA Notice of Privacy Practices Form
Download HIPPA Authorization Form

3. Office Policies *

Office expectations are outlined. We file your dental claim with your insurance carrier as a courtesy to you. Keep in mind that the final decision is made by your insurance company once they have received the claim. Any unpaid insurance portion is the responsibility of the responsible party.

Download Office Policies Form

4. Behavior Management

Our goal is to build a trusting relationship between your child and our staff. This form outlines the different strategies we use in order to achieve that.

Download Behavior Management Form (English)
Download Behavior Management Form (Spanish)

 

5. Oral Sedation Consent *

When your child receives a treatment that requires oral sedation, you will need to sign this form. Please read it carefully to be aware of the different implications of this kind of sedation.

Download Oral Sedation Consent Form

6. Medical Clearance Forms

ONLY for children that have special medical conditions like high risk cardiac conditions or similar, need a pre-authorization from their doctor before having any dental cleaning or procedure. There are 2 forms, one for new patients and one for existing patients.

Download Medical Clearance Form – New Patients Form
Download Medical Clearance Form – Existing Patients Form

7. Cancelled & Missed Appointment Policy

Our office policies regarding changes in appointment times and to be mindful of everyone’s time.

Download Cancellation and Missed Appointment Policy Form (English)
Download Cancellation and Missed Appointment Policy Form (Spanish)

8. Parents’ Authorization for Another Care Giver

Children should be accompanied by a parent or legal guardian to every appointment. When someone else is accompanying the child, please complete this form. We will also verify a picture identification.

Download Parents Authorization for Another Caregiver Form (English)
Download Parents Authorization for Another Caregiver Form (Spanish)

 

9. IV sedation “In Office” Medical Clearance Form

Before IV sedation, patients need to be seen by their pediatrician and complete the medical clearance form. This should be acquired between 15 to 5 days before the appointment.

Download IV sedation “In Office” Medical Clearance Form (English)

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