For current patients of our practice, returning for routine hygiene (cleanings) please feel free to submit the following forms for your child's upcoming appointment:
If you need help filling out these forms, please come in and a receptionist will be happy to assist you!
(for all returning patients after 6 months; must to signed by parent/legal guardian)
(If parent/legal guardian cannot attend upcoming appointment, this form may be used to authorize another adult to escort your child to their upcoming appointment. Please also notify our office by phone, so that we may obtain your verbal consent for the planned procedures).
(any changes in dental insurance since last visit; please submit prior to your child's appointment to allow time for confirmation of benefits)
All forms may be returned to our office via email: firstname.lastname@example.org.