Medicaid provider

Patient Forms

patient forms

For your convenience most of the forms you will need are located here! Filling them out in advance and bringing them with you will save you time and allow you to access any information you may only have stored at home.

NEW PATIENT FORM. Welcome! If you are a new patient with Smiles for Kids Dentistry we ask that you fill out the new patient packet before your first scheduled appointment and bring it it with you. This will help your first visit go smoother, as you will have all of the information we need to treat your child and eliminate waiting room time. Simply click the link below to download the form to your computer then print it, fill it out at your leisure, and bring it to your first appointment.

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SIBLING FORM. If you are a new family to Smiles for Kids Dentistry or are now bringing your other child or children there is no need to fill out the NEW PATIENT FORM on each child. We ask for one completed new patient form per family and one sibling form for each additional child. Simply click the link below to download the form to your computer, print it, fill it out and bring it with you on your scheduled visit.

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kid

SEDATION CONSENT FORM (English) (Spanish) . If you have scheduled a visit that you have discussed sedation with the dentist, this form gives you all of the information you need about our methods of sedation, gives us permission to sedate your child for the scheduled procedure and gives you all of the necessary information on what to expect. Simply click the link below to download the form to your computer, print it, fill it out and bring it with you on the day the procedure is scheduled.

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CONSENT TO AUTHORIZE. If anyone other than the mother, father, or legal guardian of our patient brings him/her to our office for dental care or treatment we must have written authorization. This authorization form is required for reason pertaining to HIPAA, as well as the safety of your child. Simply click the icon below to download the form to your computer, print it, fill it out at your leisure, and send it with the person bringing your child to the appointment.

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