You may access the following forms to assist us with your care. Please print and fill out the following forms, then bring them to your appointment.

Many working families rely on relatives to help by bringing the children to their appointments.  Smiles supports this, however, please keep in mind that we will need written permission from the legal guardian (s) to discuss the child's health, ask questions and gather information during the visit.

The accompanying adult may also be asked to provide decisions around treatment plans and discuss our clinical findings.

We ask that the Legal Guardian please complete the "In the Absence of a Legal Guardian or Parent" permission form below and provide it at the time of the appointment to avoid rescheduling. 

Forms for Children (Ages 1-18)

Forms for Adults (Ages 18 and older)

Existing Patient Forms

Please complete this form before each six month check-up (e.g. cleaning, recall):

Please complete this form if you had a change in insurance or demographic information:

Other Forms


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*These forms require Adobe Acrobat Reader. Click the Adobe logo above to download.