Forms for your Child's Visit
Patient Forms
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: