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Dear Parents,
Thank you for choosing our office to care for your child’s dental care. We
are delighted to welcome you to our dental family and appreciate the
opportunity to provide your child with quality dentistry and a comfortable
and fun experience. Our desire is to enter into a partnership based on
trust and mutual responsibility. Please know that your child’s needs come
first at our practice.
The following forms are enclosed:
*Medical/Dental history
*Patient privacy form (HIPPA)
*Consent to treat your child
*Insurance information
Please complete these forms and bring it with you to your appointment so
that we have all the information needed to serve your child better. For
your convenience we have also enclosed an appointment card confirming your
visit. In addition for our patients that do not have insurance, full
payment is due at the time of your visit, if you have insurance
preventative is usually covered 100%, you will however be responsible for
any co pay and deductible on the day of your visit if restorative
treatment is recommended for your child.
Our office policy on appointments is as follows, we understand emergencies
happen however, please try and give our office 24 hours notice if
cancelling or rescheduling your appointment, if you have a Saturday
appointment kindly try and give 48 hours notice. Unfortunately without
notice you can be charged $50.00 per child for a broken or missed
appointment.
If you have any questions for us prior to your appointment please do not
hesitate to call. Again, thank you for entrusting Kiddsmiles Pediatric
Dentistry with your child’s dental care. We look forward to meeting you
and your family.
Sincerely,
Kiddsmiles Pediatric Dentistry
For your convenience prior to visiting our office, please
click on the following forms, complete the information and bring them with you to your first visit.
New Patient Health History Form
Patient Consent Form
HIPAA Notice of
Privacy Acknowledgement Form
Records Request Form
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