• Patient Registration

    New to Kind Kids Dental? Please complete this form before your appointment.

  • Child's information

    Tell us about your child
  • Preferred Pronouns
  • Child's birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parent #1

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital status
  • Do you have legal custody of this child?*

  • Parent #2

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital status
  • Do you have legal custody of this child?
  • Individuals other than legal guardian authorized to bring child and consent for treatment:
  • How did you hear about us?

  • Primary Dental Insurance

  • Dental Insurance Information*

  • *If Delta Dental, include state.

  • Policy owner's birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Secondary Dental Insurance

  • Dental Insurance Information

  • *If Delta Dental, include state.

  • Policy owner's birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dental History

  • Tell us about your last dental visit:*
  • How often are the child's teeth brushed?*
  • How often are the child's teeth flossed?*
  • Who does the brushing and flossing?*
  • Fluoride Use?*
  • Does your child have any oral habits?*
  • How would you rate parent #1's oral health?*
  • How would you rate parent #2's oral health?
  • How would you rate your child's sugar consumption? (candy, juice, etc.)*

  • Medical History

  • Is your child under a physician’s care other than his/her PCP? If yes, please explain*
  • Has your child ever been hospitalized or had any surgeries?*
  • Has your child ever had any serious complications from general anesthesia?*
  • Has your child ever had a serious head injury?*
  • Does your child have any allergies? (Aspirin, Penicillin/Amoxicillin, Codeine, acrylic, Augmentin, Clindamycin, metal, latex, Sulfa drugs, local anesthesia, Zithromax)*

  • Medical Conditions

  • ADD/ADHD, AIDS/HIV Positive, Anaphylaxis, Anemia, Artificial Heart Valve, Asthma, Autism, Blood Disease, Blood Transfusion, Breathing Problems, Bruise Easily, Cancer, Cerebral Palsy, Chemotherapy, Chest Pains, Cold Sores/Fever Blisters, Congenital Heart Disorder, Diabetes, Epilepsy or Seizures, Excessive Bleeding, Fainting Spells/Dizziness, Food Allergies, Frequent Cough, Frequent Diarrhea, Frequent Headaches, Glaucoma, Hay Fever, Hearing Loss, Heart Murmur, Heart Trouble/Disease, Hemophilia, Hepatitis, Herpes, Hives or Rash, Intestinal Disease, Irregular Heartbeat, Kidney Problems, Leukemia, Liver Disease, Lung Disease, Mitral Valve Prolapse, Pain in Jaw Joints, Psychiatric Care, Radiation Treatments, Recent Weight Loss, Renal Dialysis, Rheumatic Fever, Scarlet Fever, Shingles, Sinus Trouble, Special Diet, Speech Therapy, Spina Bifida, Thyroid Disease, Tonsilitis, Tuberculosis, Vision Problems, Yellow Jaundice

  • Does your child have any of the above medical conditions, a syndrome, disease, genetic disorder, or any serious conditions not listed?*
  • Format: (000) 000-0000.

  • Policies

    • Financial Policy I have received the Kind Kids Dental Financial and Insurance Policy that outlines my financial responsibility toward care rendered by the doctors at Kind Kids Dental. I understand that the parent or legal guardian who accompanies my child to an appointment will be responsible for payment at the time services are rendered.
    • Appointment Cancellation or No-Show Policy I take full responsibility for the cancellation/rescheduling of any needed appointments. A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, WE REQUIRE AT LEAST A 24 HOUR NOTICE PRIOR TO YOUR APPOINTMENT TIME to avoid a $40 cancellation fee. Many patients are waiting months in advance for appointments, please respect our schedule and our other patients by giving us time to fill your reserved spot with another patient in need of care. Should a patient fail to keep a surgery appointment a $200 fee will be charged if advance notice is not given so that appointment may be given to another child in need of treatment. Should no advance notice of cancellation be given, Kind Kids Dental reserves the right to dismiss the patient from the practice after 3 missed or late cancelled appointments.

    • Medical/Dental Release Statements As the birth/adoptive parent or legal guardian, I give my consent for the doctors of Kind Kids Dental to complete a thorough examination on the patient named above including any needed diagnostic radiographs. To the best of my knowledge the information I have provided is accurate and I understand that it will be held in the strictest of confidence and in accordance to all federal and state HIPAA regulations. Further more, I understand that it is my responsibility to inform Kind Kids Dental of any future changes to my child’s medical history status. As a parent or legal guardian of the previously named patient, I also hereby grant the doctors and staff of Kind Kids Dental permission to perform future treatment(s) as deemed appropriate. I understand that all necessary treatment will be explained prior to commencement and that I am responsible for payment in full at the time services are rendered, unless prior arrangements have been approved.

    • Insurance Claim Release & Financial Responsibility Statement To precipitate the filing of this and all future dental insurance claims, I do hereby authorize the release of confidential information to my child’s dental insurance company. I am aware that Kind Kids Dental will be providing an estimate of the insurance coverage prior to initiating any future treatment and that I am legally responsible for any portions not paid by this policy. I understand that additional out-of-pocket expenses may be accrued should estimates provided by my insurance company be inaccurate or should procedures change during the course of the treatment. Furthermore, I am aware of my financial responsibility should my insurance policy fail to pay, for any reason, within 45 days of receiving such treatment.

    • Authorization for Direct Payment I hereby authorize payment of insurance benefits directly to Kind Kids Dental or the dentist that performs treatment on my child. Furthermore, in the event of payment default for services previously rendered, I also agree to pay all reasonable collection and/or legal fees incurred in an attempt to collect on this amount.

    • Notice of Privacy Practices, Health Insurance Portability & Accountability Act of 1996 I have read the form entitled, “Notice of Privacy Practices,” and understand its contents concerning the privacy of my child’s confidential healthcare information. I do hereby provide consent for the standard use of such information and understand that these provisions prohibit Kind Kids Dental from selling or transferring this information to any unauthorized locations without my prior approval. I have reviewed this information and all questions have been answered to my satisfaction.

    I have read and understand the above policies.

  • Photo Release

    Kind Kids Dental has my permission to use my child's photograph to promote the dental practice. I understand that the images may be used in print, online publications, website, social media, etc. I understand that no royalty, fee or other compensation will be payable to me for using the images.

  • Financial Policy and Insurance Information

  • Methods of Payment

    For your convenience we accept cash, check and credit cards (Visa, MasterCard).

    As we strive to be one of the area’s leading providers for pediatric dental care, we work to assist parents in taking an active role in their child's dental health. Because we value our relationship with you and believe that the best relationships are based upon understanding, we offer these clarifications on methods of payment & insurance reimbursement.

    Please contact Kind Kids Dental immediately after making any changes to your dental coverage, so we can keep our records current and to provide expeditious reimbursement of your benefits.

    If any treatment needs are discovered during your child’s exam, we will provide you with a cost estimate indicating our total fee, what we anticipate your insurance coverage to be, and your ESTIMATED out-of-pocket portion for the treatment plan. We will discuss all treatment options and costs before beginning any further treatment. We know that dental insurance can be confusing so feel free to contact us with insurance or payment questions.

    Dental Insurance 

    We are dedicated to providing all our patients with the best treatment available and base all our treatment recommendations on what will be best for your child and not what your insurance company does or doesn't pay. Please note the following in regards to your dental insurance coverage:

    1. We must emphasize that as a health care provider, our relationship is with you and not your dental insurance company. Your dental insurance is a contract between you, your employer and the insurance company. Most plans routinely pay between 50-75% of the average total fee for a given procedure. This percentage is pre-determined by the plan your employer has purchased.

    2. As a courtesy, we will be happy to file for your insurance benefits. Because your dental insurance plan is a contract between you, your employer, and the insurance company, many carriers will not reimburse our office. In this instance, you will be responsible for the full cost of each visit at the time services are provided and your insurance company will send you the reimbursement check directly.

    3. Any amount not covered by your insurance company is payable at the time services are rendered. These fees may include deductibles, co-payments or certain procedures not covered by your insurance policy. Unfortunately, some of the services that we may recommend for your child may not be covered by your specific dental insurance. Our primary goal is to treat your child using the best possible materials, supplies, medications and environment.

    4. We allow a maximum of 45 days for your insurance company to clear account balances. Any unpaid portions will be due in full, by you, after this period. If you have not paid your balance within 60 days of the date treatment was rendered, a finance charge of 1.5% will be added to your account each month until paid. Should your insurance company submit payment after this time, we will be glad to reimburse you. This is rare but is important that you recognize that your insurance is a legal contract between you and your insurance company. Our office is not, and cannot be part of that legal contract. Ultimately you are responsible for all charges incurred in our office.

    5. Our office does not determine your dental benefits. Your employer chooses your particular policy. If you are unhappy with it's coverage, this should be mentioned to your employer’s benefits coordinator. Only your employer can adjust benefits.

    Prior to completing any treatment, we will provide you with a cost estimate indicating our total fee, what we anticipate your insurance coverage to be, and your estimated out-of-pocket portion (estimated patient portion or EPP). Please remember, this is only an estimate based upon generalized information provided by your dental insurance company. An additional billing or possibly a refund may be subsequently required should information provided be inaccurate.

    We will always do our best to maximize the insurance benefits that you are eligible to receive and we appreciate your prompt settlement of any charges that may be incurred during the treatment process. We look forward to years of close association with you, as we work together to maintain your child's oral health!

  • Patient Code of Conduct

  • Welcome to Kind Kids Dental! We are committed to providing you with the highest quality, functional and holistic dental care in a trusting and respectful environment. This code of conduct outlines our shared expectations to ensure a positive experience for patients, their families, and our team.

    Patient Responsibilities

    1. Respect for Recommendations: We value your input and concerns. We will thoroughly explain treatment recommendations and answer your questions. However, it’s important to understand that our recommendations are based on our professional expertise and training. We kindly ask that you respect our recommendations, even if they differ from your initial expectations. You always have the right to say “no thank you” and seek another opinion, but in turn, we ask for you to respect our right to stand behind our advanced clinical expertise, knowledge, and training.

    2. Informed Consent: You have the right to make informed decisions about your child’s dental care. We will provide you with all the necessary information concerning treatment options, costs, and potential risks and benefits. We encourage you to actively participate in these discussions.

    3. Shared Decision-Making: While we encourage your questions and concerns, it’s important to acknowledge that ultimately, the dentist will determine the most appropriate course of treatment based on their professional judgement and your unique needs. If these recommendations do not resonate with you, you may find it best to seek another opinion elsewhere. Our expectation is that you do this with respect and courtesy, agreeing to disagree.

    4. Trust and Collaboration: A successful doctor-patient relationship is build on trust. We ask that you trust the advanced expertise of our providers and strongly encourage you to follow through with recommended treatment plans. If you have concerns about a particular treatment, we encourage open communication to find a solution that works for your family.

    5. Right to Dismissal: We always want a healthy and thriving doctor-patient relationship, as well as to help you have a healthy and thriving child. But if our recommendations surrounding diet, hygiene, treatment needs, and high-priority referrals are not followed or respected, we cannot fulfill our commitment to improving patient health and outcomes. In the event of a persistent disagreement with our treatment recommendations, a lack of trust in our plan or our providers, or disrespect to our doctors or our team members, we reserve the right to dismiss you from the practice. This dismissal would be based on the inability to establish a collaborative and amicable doctor-patient relationship necessary for effective treatment.

    Our commitment to you:

    • We will treat you with respect, courtesy, and compassion.
    • We will listen attentively to your concerns and answer your questions.
    • We will provide you with all the information you need to make informed decisions about your child’s dental care.
    • We will work collaboratively with you to develop a treatment plan that is not only right for your child, but that is also safe and effective based on our decades of clinical experience and advanced training.

    We look foward to partnering with you on your journey to optimal oral and whole-body health!

    By signing below, you acknowledge that you have read and understand this Code of Conduct.

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