• New Patient Paperwork for Children

    Welcome to Palmetto Smiles! Please fill out all pages on this form to the best of your ability so that we may prepare for your child's first appointment.
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  • Medical History

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  • Dental History

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  • Primary Dental Insurance Only

    Please note we are not a participating or contracted provider with any insurance plan. We will verify your orthodontic benefit for you prior to your consultation.
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  • Office Policies

    Please click the link, review our office policies and sign below to indicate you have read and understand our policies.
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  • Acknowledgement of Receipt of Notice of Privacy Practices

    You may refuse to sign this acknowledgement. Please click the link, read and sign below to indicate you have read and understand the Notice of Privacy Practices.
  • I, , have received a copy of this office's Notice of Privacy Practices.

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  • Authorization Compound

    This authorization form permits Palmetto Smiles 139 Whiteford Way Lexington, SC 29072 to use or disclose protected health information listed in the description sections below to the Entity or Person listed in each section.
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