Fort Mill Grand Opening Special
FREE New Patient Exams Age 12 & Under
September 30th Only!
We Welcome New Patients
Our experienced team is eager to join your child on their dental health journey. To request an appointment at Charlotte Pediatric Dentistry, please use the request form on this page or call us directly at 704-327-6819
During your child’s appointment, we will take the time to explain our treatment process and answer any questions you may have. We look forward to building the foundation for your child’s lifelong healthy smile!
New Patient Forms
Prior to your child's appointment, please take a moment to download, print, and fill out the appropriate forms below. Please bring the forms with you to your child's appointment. We look forward to meeting you and your child!
English
- Download/View the New Patient Form
- Download/View the Consent To Treat and Family/Friends Form (Adobe PDF) This form is if someone other than the parents will be bringing the child to the appointment.
- Download/View the Financial and HIPAA Information Form (Adobe PDF)
- Download/View the Authorization to Release Health Information Form (Adobe PDF)
- Download/View the Authorization to RECEIVE Health Information (Adobe PDF)
- Download/View the Patient Recall Form (Adobe PDF)
En Espanol
- Información del Paciente (Adobe PDF)
- Consentimiento para el tratamiento de Pacientes (Adobe PDF)
- Poliza de Pagos for Honorarios (Adobe PDF)
- Autorización Para Enviar Información De Salud (Adobe PDF)
- Autorización Para Recibir Información De Salud (Adobe PDF)
- Formulario de Recuerdo Del Paciente (Adobe PDF)
Fill Out the Form Below to Request Your Child's Appointment Today
Contact Information
*Please do not submit any Protected Health Information (PHI). This is not a secure or encrypted means of communicating with our offices.
