New Patient Forms
Most children, especially infants and toddlers, don't do well with waiting for the parent to complete extensive paperwork and insurance verification. In order to make your child's first visit as fun as possible AND save you time. See below for the ways you can complete the forms needed to become a patient and start your child on the path of a healthy smile for life!
Use the forms below to fill out your new patient information online prior to your first visit.
New Patient Form - English - Please fill out the entire New Patient Form.
New Patient Form - Spanish - Por favor complete el formulario completo para pacientes nuevos.
You can print the below forms and fax or mail the completed forms below to our office. This will allow us to start your family record and verify insurance PRIOR to the first appointment. After we receive those forms and enter them into a family file, one of our staff will call you to set up an appointment time that works best for your child's age group and your schedule as well as review your insurance benefits with you.
Welcome Kids Sheet - Please fill out the entire Welcome form.
Financial Guidelines and Dental Insurance - Please read carefully and sign.
Financial & Insurance Policy - Please read carefully and sign.
Federal Requirements Regarding Patient Privacy (HIPAA) - READ ONLY In order to comply with federal law regarding patient privacy, please read this document.
Patient Privacy Acknowledgement Form - - Please read carefully and sign.
Office Policies and Procedures - Please read carefully and sign.
Please make sure that all information is completed and mailed or faxed back to our office, upon receiving this information, someone from our office will contact you to schedule your child's initial visit.
Our staff is committed to helping our parents feel comfortable and worry free. Please call our office with any questions or concerns you might have.
Thank you, Dr. Divya Iyer & Staff
1 Eureka Circle #103 Wichita Falls, TX 76308
Contact Us with any questions: email@example.com