Pediatric Dentistry of Hamburg: Lexington Office New Patient Forms

2517 Sir Barton Way, Suite 200, Lexington, KY 40509 | (859) 543-2456

First NameMiddle NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

Both parentsMotherFatherOther

MarriedDivorcedSingleWidowed

Person to be contacted in an emergency (other than parents).

First NameMiddle NameLast Name

Please enter a valid phone number.

ONE parent is permitted to remain with each child during treatment (other than sedation appointments). Dr. Jackson, Dillow, Day, Luley, or Haggerty will discuss with you the terms and conditions for this privilege. Other guests/siblings must remain in the waiting room accompanied by an adult.

We request that 24-hour notice be given if you cannot bring your child for their scheduled appointment. You will be charged $25.00 for broken appointments when illness is not a factor and 24-hour notice is not given.

I have fully read and understand the above APPOINTMENT & CANCELLATION POLICIES and accept all provisions.

Please enter a valid phone number.

I hereby acknowledge that the information provided above is a true representation of my child's medical and dental history/condition.

Yes, I give permissionNo, I do not give permission

Pediatric Dentistry of Hamburg: Lexington Office New Patient Forms

DEMOGRAPHIC INFORMATION

TREATMENT AUTHORIZATION / FINANCIAL AGREEMENT

APPOINTMENT & CANCELLATION POLICIES

MEDICAL HISTORY

PHOTO RELEASE