Pediatic Patient Form

Please fill out our form below or click on the button below to download. To help ensure your well being while undergoing treatment in our office please answer the following questions in detail. Information will be considered confidential and for our records only.

Download
Pediatric Form
  • Patient Information
  • Contact Information
  • Medical Information
  • Insurance Information
  • Photo/Release Acceptance

This is to certify that I, undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable, including the use of local anesthesia and any necessary sedation as indicated. I agree to make payment for services upon completion at each appointment, by cash, cheque or credit card unless other arrangements have been previously and specifically made with the dentist.

I also understand that there will be a charge for appointments missed without sufficient notice.