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Call: 724-941-5000

Forms

Patient Forms


Please do not fill out Patient Forms without a

scheduled appointment. Thank you!

Patient Forms

  • New Patient Forms

    These forms must be completed for all scheduled new patients.




    Open Form List Item 2

Patient Forms

  • Returning Patient Forms

    Please fill out these forms to update your child's dental and medical history as well as any changes in address, phone or insurance information if your child is being seen for a dental cleaning or updated dental exam.

    Open Form List Item 1

Patient Forms

  • Health Questionnaire

    Please fill this form out 24 hours prior to your child's scheduled appointment.

    Open Form
  • Consent for Treatment of a Minor

    Parent/Legal Guardian to fill this form out when they will NOT be present to accompany their child(ren) to their dental appointment.

    Open Form
  • Consent to Discuss Health Information

    Parent/Legal Guardian to fill this form out and list any parties who may have access to their child(ren)’s dental records.

    Open Form
  • Silver Diamine Fluoride Consent

    Open Form
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3402 Washington Rd, McMurray, PA 15317
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