Child New Patient Form

Dentist In Kalamazoo, MI

  • General Information

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  • Insurance Information

  • Dental History

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  • Health History

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  • Social Media & Website Consent Form

    First of all, thank you! Thank you for selecting Gentle Dentistry. We would love to post your review, picture, and experience here online at, within our website. If you would like to take part in recognizing our office online within our patient section, homepage or testimonial on our website, Facebook or Twitter, please sign below. This form states that you freely give consent to take part in our website, and authorize that your first name and only initial of your last name can be publicly displayed within Gentle Dentistry's website. You understand that by signing this form you are agreeing to take part in our online media source(s) and website. You have received a copy of this form to take with you, as well. We, the staff here at Gentle Dentistry, thank you; we are happy to have you as a patient here for all your dental health care needs.

  • Witness Statement

    I confirm that I was present for the verbal and written statement summary presented to the patient mentioned above, as well as the execution of this form. I agree that the information was accurately explained to, and apparently understood by, and that informed consent was freely given by the patient.

  • Written Financial Policy

    Thank you for choosing Gentle Dentistry. Our primary mission is to enable our patients to achieve excellence in oral health and freedom from head and neck pain. We will make every effort to provide quality dentistry in a caring and pleasant atmosphere.

    Payment Options

    Full payment is expected at the time of service. You may choose from:

    • Cash, check, credit card (Visa, MasterCard, Discover, and American Express), debit card, HSA, FSA
    • Payment Plans from CareCredit
  • Insurance

    We may accept assignment of insurance benefits providing all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer, and the insurance company. You, the patient, have the ultimate financial responsibility for treatment. If any services are rejected by your insurance carrier, you are responsible for the fees. If we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits from your insurance carrier. Accounts not paid within 30 days are subject to a monthly statement fee and may be recovered through a collection agency.

    All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid. The payments have nothing to do with the actual charges. The treatment recommended by our office is never based on what your insurance company will pay but what your dental health needs are; your treatment should not be governed by your insurance contract.

    Please take the time to review your insurance contract thoroughly so we may best serve you and help you to receive the maximum benefits toward your dental health. As always, you may feel free to ask any member of our team for clarification on services, billing, and insurance.

  • Cancellation Policy

    We would greatly appreciate a 48-hour notice from any patient (or patient representative) should they need to reschedule or cancel an appointment. We reserve the right to apply a cancellation fee if this policy is not respected.

    If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you need or want.

  • I have read this policy, understand and agree to it.

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    You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

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  • The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.




    (This includes step parents, grandparents and any care takers who can have access to this patient’s records):

  • In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you with this information with your knowledge and consent.


    1. I hereby authorize and direct the dentist(s) of Gentle Dentistry and/or dental auxiliaries of his/her choice to perform upon my child (or legal ward) the following dental treatment or oral surgery procedure(s); Including the use of any necessary advisable local anesthesia, radiographs (x-rays), or diagnostic aids.

    • Cleanlng of the teeth and the appllcation of topical fluoride.
    • Application of plastic "sealants" to the grooves of the teeth.
    • Treatment of diseased or injured teeth with dental restorations (fillings) or crowns (caps).
    • Replacement of missing teeth with dental prosthesis.
    • Removal (extraction) of one or more teeth.
    • Treatment of diseased or Injured oral tissues (hard and/or soft).
    • Pulp (nerve) treatment on one or more teeth.
    • The removal (excision) of diseased, inflamed hard and soft tissue tumors or lesions.
    • The placement of sutures for wound closure.
    • The placement of splints or appropriate wound dressings.
    • The repositioning of one or more teeth.
    • Tooth bleaching.

  • 2. I understand that there are risks involved In the treatment and hereby acknowledge that these risks have been explained to me, that I have had an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.

  • 3. I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor(s). I understand that nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nose piece leaves an Indentation or ring around the nose which disappears shortly after the procedure.

    • This treatment has been explained to me. Alternate methods of treatment, if any have also been explained to me, as have the advantages, disadvantages and risks of each. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there cannot be a guarantee either expressed or implied, as to the result of the treatment or as to the cure.
    • I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I, therefore, authorize and request the performance of any additional procedures that are deemed necessary or desirable to my child's oral health and well-being in the professional judgment of the dentists of Gentle Dentistry.

  • 4. I understand and have been Informed that there are possible risks and complications associated with the administration of local anesthesia, nitrous oxide, and drugs. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the Injection site), fainting, lip and cheek biting resulting In ulceration and Infection of the mucosa.

  • 5. I also authorize the doctors to use photographs, radiographs, other diagnostic materials and treatment records for the purposes of teaching, research and scientific.

  • 6. The alternatives to these methods of treatments are:

    • Do nol pertorm the recommended treatment.
    • Referral to a specially dentist of pediatrics.

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  • This field is for validation purposes and should be left unchanged.

Emergency Dental Care

Our dental office treats many types of traumatic dental injuries, such as teeth that have been chipped, moved, or knocked out. Please contact our Kalamazoo, MI office for help with a dental emergency.

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