New Patient

We welcome your child into our practice and we will try to make his/her dental experiences very pleasant.  Please complete the online Registration Form below or print out the Patient Registration Form  and bring it with you to your next dental appointment.

Items in bold indicate required information.

Patient Information


Whom may we thank for referring you to our practice?

Health Information

Has your child ever had any of the following?











































Parent Information

Father's Information


Address
Is the father's address the same as the patient's address that you have already entered above? Click the button below to copy the information.
Use the patient's address

Mother's Information


Address
Is the mother's address the same as the patient's address that you have already entered above? Click the button below to copy the information.
Use the patient's address

Insurance Information



I hereby authorize payment of the dental benefits otherwise payable to me, directly to Barnes & McDonnell Pediatric Dentistry.

Insurance Policy

Since our office comes in contact with many different insurance companies which consist of different policies, we do ask that each parent or person responsible for their child's account to take care of the amount charged as the treatment is completed on each visit. we will be more than happy to assist you in filing your insurance.

Non-Insurance Policy

To reduce the increased cost of billing, payment is required at the time services are rendered. We accept personal checks, cash, Visa, Mastercard, Discover, AMEX, and CareCredit. Thank you for your cooperation.

Consent For Services

Your child is a minor; therefore it is necessary that a signed permission be obtained from a parent or guardian before any necessary dental treatment can be rendered. I grant Barnes & McDonnell Pediatric Dentistry permission to provide my child's dental exam and treatment, using patient management and restorative techniques that are proper and acceptable. An appropriate explanation either oral or written will be given to parents preceding any dental treatment, services, medications operations, behavior management, techniques, local anesthesia and analgesia necessary for my child's dental needs. I understand that the treatment plan to be presented, as well as the fees outlined, could change depending on the time elapsed since the initial examination and the extent of dental decay.

I have read this release and am fully familiar with its contents.


Acknowledgement of Receipt of Notice of Privacy Practices
Notice of Privacy Practices
have received a copy of this office's Notice of Privacy Practices.





Thank you for taking the time to fill out these forms accurately.  This helps us better serve your child.