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NEW PATIENT FORMS – Please print and complete one form for each child. If you have more than one child coming to our office, you will only need to complete one Financial Agreement, General Patient Information and HIPAA Authorization Form for your family.

 

ADDITIONAL FORMS:

  • Additional Caregiver Consent– Please complete if there will be additional people bringing your children to their appointments
  • Authorized Release of Information – Please complete this form when records should be transferred to or from another dental office
  • Minnesota Health Care Program Waiver – Pediatric & Adolescent Dentistry will file UCare, Blue Plus and Medica through age 4. We do not file with PrimeWest. This document should be completed if your child has one of these insurances.