TENDER CARE PEDIATRIC DENTISTRY FORMS

You can save time for your first dental visit by printing and completing the following forms to bring to your appointment.

A parent or legal guardian must accompany the child to the first visit.

Complete New Patient Packet

Complete New Patient Packet- Please print and complete this packet for your first appointment.

Individual Forms

If you prefer to download the forms individually, please click on the links to view each form and print them.

New Patient Form - Please print and complete this form for your first appointment.

Parent Guidelines - Please read these guidelines before your first visit.

Practice Terminology - Please use this list of words to ensure your child has a successful first visit.

Notice of Privacy Practices - Please read to learn about our privacy practices.

Receipt of Privacy Practices - Please print and sign to acknowledge you have received and read our privacy practices.

Authorization For Treatment of a Minor - Please print and sign for authorization of someone other than a parent/legal guardian to bring your child to an appointment. Parent/legal guardian must accompany child to first appointment.

WHO CAN ACCOMPANY YOUR CHILD?

A parent or legal guardian must accompany the child to the first visit. A photo ID for the parent/guardian is also required during this visit. After the initial visit, if a grandparent or someone other than parent/legal guardian is accompanying the child, they must bring a note from the parent/legal guardian granting the accompanying adult permission to make medical and financial decisions.

10 MINUTE LATE POLICY

In order for us to effectively serve all of our patients, anyone who is 10 or more minutes late for their appointment will be rescheduled.

SCHOOL AND HEAD START EXAMINATION FORMS

School and Head Start examination forms will not be accepted by fax. All forms must be mailed or dropped off at the office in order to be completed.
Forms that are mailed or dropped off must have child's name and information filled out prior to us completing form. Any form received without child's name will not be completed.

There is a $3 fee for school forms that must be paid at time of completion. If you are mailing a school form, please include a check made payable to Tender Care Pediatric Dentistry. There is no fee for head start forms.