We would like to welcome the new patients that have joined our family.
We know the selection of a professional dental practice for your child is important and we appreciate your choosing our practice. We hope we exceed your expectations. Thank you for allowing us to be an integral part of your family! Should you have any questions, please call 704-377-3687.
English:
- Download/View the New Patient Form (Adobe PDF)
- 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 Notice of Privacy Practices (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)
Please Note:
Federal law requires all healthcare practices to obtain, verify, and record information that identifies each new patient.
What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
