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.

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 that 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.

Kiddsmiles Pediatric Dentistry

(For your convenience prior to visiting our office, please complete the information and bring them with you to your first visit.)


New Patient Health History
Patient Consent
Patient Privacy
Records Request