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Patient Registration Forms

Welcome to Westside Children's Dentistry! We look forward to providing your children outstanding oral health care in a compassionate and pleasant environment. The office is designed to promote your child's comfort while creating a positive dental experience. A friendly staff, and fun surprises are available to all patients.

At your child's first visit, please bring your COMPLETED registration form, health history, and Privacy Practice signature form to your visit. A parent or legal guardian must be present at the first visit in order for us to examine and treat your child. The first visit will include a comprehensive exam, and may include a cleaning (dental prophylaxis), fluoride treatment and X-rays if needed. We utilize a digital x-rays.

Payment will be due at time of service. As a courtesy, we are able to forward claims to your insurance carrier for you. In order for us to bill your insurance, you will need to provide all insurance, subscriber, and billing information on the attached registration form. Please take your insurance card to the appointment.

Your appointment time is considered a confirmation of the appointment. Since our specialty is kids, we understand that you juggle school, activities, and family commitments and may occasionally need to change your scheduled appointments. Just give us a call, and we can help you with that too!

As we will have reserved that time especially for your child, please call us at least 48 hours in advance of the appointment if you need to find another time that works.

Included in this packet:

 

  • Patient registration form
  • Patient Health History
  • Appointment Reminder Card
  • Notice of Our Privacy Practices
  • Signature Form (verifies that you have received a copy of our Privacy Practices)

 

We specialize in the treatment of children and adolescents. All staff members are trained not only in the clinical care of children, but to promote healthy oral habits in even the youngest of patients. We believe that hygiene, age-appropriate instruction and self-care are great steps towards a healthy smile. Thank you for your trusting us with your children's oral health!

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Office Hours:

Monday thru Friday 7:30am-4:00pm with a lunch from 12:30-1:30pm daily

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