Home New Patient Form for Children and Teens
For your convenience, our new patient forms can now be filled out and submitted online. Please note that this form is for patients who are under 18 years of age. If you are a patient who is 18 years of age or older, please fill out and submit our new patient form for adults. In compliance with HIPAA regulations, all information submitted is encrypted. To further protect the privacy of your data, we do not store or maintain copies of any patient data on our website.
The PDF version of our new patient form is available for patients who prefer to download and complete the form offline.
Please enter your address information below:
Please provide the responsible party's details below.
Contact should be a friend or relative NOT living with you.
Is your child allergic to any of the following?
Has your child ever had any of the following?
Does your child do / have any of the following?
I authorize this office to affix my name to any and all claims or documents related to any and all dental benefits due me and my dependents through my employment. I authorize payment of dental benefits otherwise payable to me, directly to this office.
I understand that where appropriate, credit bureau reports may be obtained.
I certify that I have read and understand the foregoing questions. To the best of my knowledge, the foregoing questions have been completely and accurately answered. In addition, I will notify the doctor of any change in my health history.
Before submitting this form, the patient's parent / guardian must click the checkbox below indicating that you have read and agree to our HIPAA Privacy Statement and then enter your signature in the space provided below.