New Patient Form – 2

You may complete this form online, and the information will automatically be sent to our office.

Return to the main Forms page.

  • Parent/Guardian Information

  • Child's Information

  • I authorize routine dental diagnostic procedures for my child. If I accept the proposed treatment plan for my child after examination, I also agree to the use of anesthetics and pre-medications considered necessary or advisable by the dentist for the comfort and well being of my child.

    As a courtesy to you, our office will bill your insurance. We do our very best to collect from your carrier. However, we must inform you that YOU are ultimately responsible to know your benefits and for any and ALL account balances. All past due balances are subject to a finance charge of 1 ½ % per month, which is an annual rate of 18% and/or are subject to all legal and collection expenses. Cancellation fees may apply after 48 hrs. of notice.