Pediatric forms - Jacksonville pediatric dentist - Bean Tree Pediatric Dentistry

Forms for your Child's Visit

Forms are never fun to fill out – especially the medical kind. That’s why we’ve made our forms patient-friendly and will offer multiple options for getting your child’s dental- and medical-history information to us.

Patient Forms

We’ve gone completely digital with our forms. All you need to do is click the buttons below the form you need to complete and you will be taken to the page where you can fill-in the information, click the submit button and then go enjoy your day. The forms will be transmitted to us securely and attached to your account.

You may read our Statement of Privacy Practices here.

New Patients

Registration, Health & Dental History

Information needed: child’s name, parents’ names, insurance, dental and medical history. Describes our privacy policy, information disclosure, general treatments (opt-out) and needs your signature.

Current Patients

Health & Dental History Update Form

Information needed: child’s and parent’s names. We ask that this be completed anytime your child’s health or dental history, insurance, address, phone number or email address has changed.

Dental Treatment Consent Forms

Extraction Consent

Extractions of primary or permanent teeth may be necessary due to extensive caries (decay), infection…

Composite Filling Consent

Teeth with caries (decay) may be restored with composite (white) or amalgam (silver) filling material…

Frenectomy Consent

In order to treat this condition, Dr. Mason has recommended that a frenectomy be performed at…

Nitrous Oxide Consent

Nitrous oxide/oxygen inhalation is a mild form of conscious sedation used to calm an anxious patient.

Pulpotomy Consent

A tooth with extensive caries (decay) that approaches or enters the nerve of the tooth may require a nerve…

Sealants Consent

Sealants help to prevent caries (decay) in the pits and grooves of posterior (back) teeth. They do…

Silver Diamine Consent

The use of silver diamine fluoride in dentistry has been well documented for its safe and successful ability to control tooth decay. Its application is a conservative approach for the…

Space Maintainer Consent

When baby teeth (molars and canines) are lost prematurely, it is usually necessary to place a space maintainer in order to prevent teeth from shifting into the space created…

Stainless Steel Crown

A tooth with extensive caries (decay) often requires a full-coverage restoration called a stainless steel crown. A stainless steel crown helps to protect the tooth against further…

Refusal of Treatment

You have the right and the obligation to make decisions regarding your healthcare . Your dentist can provide you with the necessary information and advice, but as a member of the…

Release of Records Request

Need to request records? Use the Records Release form to have your child’s records sent to you or another provider’s office.

Still Have Some Questions?

We have the answers. If you can’t find what you’re looking for on this page, we recommend the following:

Contact Us
Call (904) 372-3260 or email the BeanTeam.
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