New Patient Forms

Welcome new pediatric dental patients! Our caring team provides gentle, comprehensive dental care tailored for children. Schedule your appointment today!

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New patients are required to fill out the form below.

Patient Information

Child's Name(Required)

First Last

Nickname

Child's Gender(Required)

Male

Female

Child's Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State ZIP Code

School

Hobbies/Sports

Name of parent/guardian (who will be accompanying child)(Required)

First Last

Do you have legal custody of this child?(Required)

Yes

List brothers/sisters and ages

Patient Dental History

Previous Dental Office

Primary Parent/Guardian Information

Your relationship to child(Required)

Other relationship, please specify(Required)

Your Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone #(Required)

Contact Type(Required)

Mobile

Home

Work

Alternate Phone #

Contact Type

Mobile

Home

Work

Email(Required)

Enter Email Confirm Email

Employer

Date of Birth(Required)

MM slash DD slash YYYY

Secondary Parent/Guardian Information

Is there a secondary parent/guardian?(Required)

Yes

Your relationship to child(Required)

Other relationship, please specify(Required)

Your Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone #(Required)

Contact Type(Required)

Mobile

Home

Work

Alternate Phone #

Contact Type

Mobile

Home

Work

Enter Email Confirm Email

Employer

Date of Birth(Required)

MM slash DD slash YYYY

Dental Insurance

Do you have dental insurance?(Required)

Yes

Insurance Company Name(Required)

Policy Holder

Policy Holder Social Security Number (SSN)

ID#

Group #

Phone #

Do you have secondary dental insurance?

Yes

Insurance Company Name

Policy Holder

Policy Holder Social Security Number (SSN)

ID#

Group #

Phone #

Medical History

How did you hear about our office?

What are your concerns regarding your child's smile, bite, and/or teeth?

Is your child in good health?

Yes

Patient's Physician Name

First Last

Physician's Phone

Patient's Last Office Visit

MM slash DD slash YYYY

Is your child allergic to Nickel?

Yes

Is your child allergic to Latex?

Yes

Does your child have allergies? If so, please provide them.

Is your child currently taking any medications?(Required)

Yes

Medications your child is currently taking:(Required)

Has your child ever been hospitalized?(Required)

Yes

Please explain:(Required)

Does your child need to be pre-medicated with antibiotics before dental treatment?

Yes

Has your child experienced clicking sounds or pain of the jaw joints upon opening/closing of the mouth?

Yes

What of the following habits does your child have? (check all that apply)(Required)

None

Lip biting/sucking

Mouth breathing

Nail biting

Thumb/finger sucking

Teeth clenching/grinding

Tongue thrust

What of the following medical problems does your child have? (check all that apply)(Required)

None

Allergies

Anemia

Asthma

Blurred vision

Diabetes

Difficulty in breathing

Difficulty in sleeping

Difficulty in swallowing

Dizziness/fainting spells

Emotional Problems

Headaches

Hearing problems

Heart problems/murmur

Hepatitis

Herpes

HIV/AIDS

Kidney disease

Learning difficulties

Neck/jaw/head injury

Pain in jaw/head/neck

Radiation treatment

Recent weight loss

Rheumatic fever

Seizures/epilepsy

Sinus problems

Skin disorders

Speech difficulties

Stomach problems/ulcers

Thyroid disease

Tumors/cancer

Any other medical problems/procedures not listed above?

Parent/Guardian Consent

Consent(Required)

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my child's medical history. I authorize the Doctors and the staff at Bel Air Pediatric Dentistry to perform necessary dental services associated with my child's dental care. I authorize Bel Air Pediatric Dentistry to submit fees for rendered services to the listed insurance company(s) for payment, I understand that I am responsible for payment of services at the time they are rendered.(Required)

Parent/Guardian Name(Required)

First Last

Relationship to patient(Required)

Other relationship, please specify(Required)

Patient's Name(Required)

First Last

Authorization and Final Agreement

If your account shows a balance, you will receive a statement each month, even if insurance has been submitted for you. All fees incurred with this office for services rendered will be due at the time of service unless previous arrangements have been made. If, for any reason, the bill is outstanding after 60 days, a late charge will be added to your balance in the amount of 1.5% per month which is an annual rate of 18%.

Insurance: We will be happy to complete and file your insurance forms to aid you in collecting full benefits according to your insurance plan. Patients who have dental insurance should be advised that the professional services rendered are charged to the patient and not the insurance company. You are responsible for any portion not paid by your insurance company, including any co-payments, deductibles, fees over your insurance company's UCR, etc. Even though an insurance claim has been filed, you will receive a statement each month if your account has a balance due. It helps us get your full benefits if you list complete dental insurance information on the previous page for all insurance plans.

Responsibility: We realize that many families are in a state of change. Divorced, separated, single parent and blended families are now common. In many of these families the question of who is responsible for the child's dental bills is uncertain. In the case of separated or divorced families we will need to have this form signed by the financially responsible party, otherwise the accompanying parent is responsible.

If you have any questions, please feel free to discuss them with the receptionists.

Child's Name(Required)

First Last

Consent(Required)

I have read the office policy and request that your office provide dental care. I authorize release of any information relating to any insurance claims. I hereby authorize payment directly to the dentist of the insurance benefits otherwise payable to me.(Required)

I understand that by signing this form I am hereby accepting responsibility for any and all fees incurred with this office.

Your Name(Required)

First Last

Relationship to child(Required)

Other relationship, please specify(Required)

Social Security Number (SSN)

Any amendments to this agreement must be discussed with the office manager and another form signed before any services are rendered. No handwritten amendments to this form will be accepted.

Acknowledgement of Receipt of Notice of Privacy Practices

Consent(Required)

I have reviewed this office's Notice of Privacy Practices.(Required)

Patient Name(Required)

First Last

Consent for Treatment(Required)

I am the parent/guardian of the minor child. I authorize examination of and treatment as necessary by or under the supervision of Dr. Kapil Davar or Dr. Vidhima Davar at Bel Air Pediatric Dentistry LLC. This includes exposure of radiographs (x rays) as necessary, cleaning, fluoride application, use of local anesthetic and/or nitrous oxide (laughing gas, if necessary), fillings/extractions/ crowns (if necessary) , reasonable restraint as needed, and use of appropriate medicaments and materials for such treatment.

I have read and understand the above information. By my signature below I consent to the treatment described above.

Parent/Guardian Name(Required)

First Last

Broken Appointment Policy
We strive to provide excellent care to our families and reserve time specifically for your child to be seen. We understand and try to accommodate the schedules of parents and make every effort to see your child in a timely manner. Therefore we request that you extend us and our other parents the same courtesy by informing the office at least 24 hours in advance if you are unable to keep your appointment. There maybe a $30.00 missed appointment charge per child to your account if you do not provide our office 24 hours cancellation notice. We also reserve the right to terminate professional treatment of any patient who continually fail to keep their scheduled appointments.

We would like to remind you about your appointment. What methods would work best for you?(Required)

Text (SMS)

Phone

New Patient Forms

Patient Information

Patient Dental History

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Dental Insurance

Medical History

Parent/Guardian Consent

Authorization and Final Agreement

Acknowledgement of Receipt of Notice of Privacy Practices

Schedule your child's six-month exam and cleaning

Bel Air Pediatric Dentistry

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