Patient Forms

patient forms

For your convenience, most of the forms you will need are available here! Filling them out in advance and bringing them with you will save you time and enable you to access the proper information needed before your visit.

NEW PATIENT FORM Welcome! If you are a new patient with Smiles for Kids Dentistry, we ask you to fill out the new patient packet before your first scheduled appointment and bring it in with you. This will help your first visit go smoother, because you will have all the information we need to have your child treated and reduce time in the waiting room. Simply click the link below to download the form to your computer; then print it, fill it out at your leisure, and bring it to your first appointment.

If you are a new family to Smiles for Kids Dentistry, or are now bringing another child or additional children, there is no need to fill out the NEW PATIENT FORM for each child. We request only one completed new-patient form per family and one sibling form for each additional child. Simply click the link below to download the form to your computer, print it, fill it out, and bring it with you on your scheduled visit.

Siblings Packet

SEDATION CONSENT FORM If you have scheduled a visit and have discussed sedation with the dentist, this form provides all the information you need about our methods of sedation, gives us permission to sedate your son or daughter for the scheduled procedure, and includes all the necessary information about what to expect. Simply click the link below to download the form to your computer, print it, fill it out, and bring it with you on the day the procedure is scheduled.

CONSENT TO AUTHORIZE If anyone other than the mother, father, or legal guardian of our patient brings him or her to our office for dental care or treatment, we must have written authorization. This authorization form is required for reasons pertaining to HIPAA, the Health Insurance Portability and Accountability Act, as well as the safety of your youngster. Your understanding and cooperation is greatly appreciated. Simply click the link below to download the form to your computer, print it, fill it out at your leisure, and send it with the person who brings your child to the appointment.

Privacy Policy





Our legal duty

We are required by federal law to maintain the privacy of your health information.  We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information.  We must follow the privacy practices that are described in this notice while in effect. 

We reserve the right to change our privacy practices and terms of this notice as permitted by law at any time. New terms of the privacy practices will be effective for all health information that we maintain including, health new information we created or received before we made the changes. If we do make a significant change to this notice we will make the new one available upon request.

Uses and disclosures of health information

We use and disclose health information about you for treatment, payment and healthcare operation.  For example:

Treatment: we may use and disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.  Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation certification licensing or credentialing activities.

Your authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information to disclose it to anyone for any purpose.  If you give us authorization you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.  Unless you give us written authorization we cannot use or disclose your health information for any reason except those described in this notice. 

Your family and friends:  we must disclose your health information to you, as described in the patient rights section of this notice.  We may disclose your health information to a family member, friend or any other person to the extent necessary to help with your healthcare, but only if you agree that we may do so. 

Persons involved in care:  we may use or disclose health information to notify or assist in the notification of (including identifying or location) a family member, your personal representative, or another person responsible for your care, your location,  your general condition or death.  If you are present then prior to use or disclosure of your health information, we will provide you an opportunity to object to such uses or disclosures.  In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare.  We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar form of health information. 


Marketing health related services:  we will not use your health information for marketing communications without your written authorization.

Required by law:  We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes.  We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security:  We may disclose to military authorities the health information of armed forces personnel under certain circumstances.  We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence and other national security activities.  We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmates or patients under certain circumstances.

Appointment Reminders:  We may use or disclose your health information o provide you with appointment reminders such as voicemail messages, postcards or letters.



Access: You have the right to look at or get copies of your health information with limited exceptions.  You may request that we provide copies in a format other then photocopies.  We will use the format you request unless we cannot practically do so. (You must make a request in writing or sign the proper forms in our office to obtain access to your health information).

Alternative Communication: you have the right to request that we communicate with you about your health information by alternative means or an alternative location. You must make your request in writing and must specify the alternative means or location and provide satisfactory explanation.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do we will abide by our agreement (except in an emergency).

Amendment:  you have the right to request that we amend your health information (your request must be in writing and must explain why the information should be amended), We may deny your request under certain circumstances.


Questions and complaints

If you want more information about our privacy practices or have questions or concerns please contact us. 

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint upon request.

We support your right to the privacy of your health information.