New Patient Form

We are so excited to share our new office with you, and hope that you enjoy it as much as we do! Please take this time to review some information we feel will make your visit as pleasant as possible.
Patient Safety
Every patient’s health is very important to us; from the waiting room to the treatment room we want to give you quality care. Many of our patients have allergies that could be at risk, so we do ask that you do not bring food and drink into the office of any kind. Our office only uses latex free and BPA free products. We use digital radiographs to ensure your child gets the least amount of radiation possible.
Photography/Videography
We understand that a new office is very exciting, and lots of things to see. However, photography/videography is not allowed due to the privacy of our other patients. If you would like a picture for social media or a scrapbook, just ask! We would be happy to find you a special place to take a picture with Dr. Crews or your favorite team member.
Treatment Areas
A lot of planning has been made in order to give you the best possible experience at our office, and our goal is to make your experience as efficient as possible. Your time is very important to us, but please understand Dr. Crews’ time is important too. Please silence all phones prior to being called back to ensure we communicate effectively in regards to your child’s treatment. In order to keep the patient flow in the treatment areas, we ask that only one person come back with each patient. The new office is not able to accommodate multiple children in the back. Therefore, children not being seen must remain in the waiting room and be accompanied by an adult.

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Treatment Authorization / Financial Agreement
Child's Name*
Child's SSN
Sex*
- Male
- Female
Child's Age*
Child's DOB*
Child's School*
Do we see other children in our family?*
- Yes
- No
Names*
Father's Name*
Father's DOB*
Father's SSN
Father's Address*
Street Address City State ZIP Code
Father's Phone
Father's Cell Phone
Father's Employer
Father's Employer's Phone
Mother's Name*
Mother's DOB*
Mother's SSN
Mother's Address*
Street Address City State ZIP Code
Mother's Phone
Mother's Cell Phone
Mother's Employer
Mother's Employer's Phone
Child Resides with*
- Both Parents
- Mother
- Father
- Other

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Name of Dental Insurance Carrier
SSN of Insured
Is insurance carried through employer?
- Yes
- No
Group Number
Name of Health Insurance Carrier
SSN of Insured
Is insurance carried through employer?
- Yes
- No
Group Number
Phone Number for Confirmation of Appointments*
Emergency Contact Name*

Person to be contacted in case of emergency (other than parents)
Emergency Contact Relation*
Emergency Contact Phone*

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Appointment and Cancellation Policy

One parent is permitted to remain with each child during treatment (excluding sedation appointments). Dr. Crews will discuss with you the terms and conditions for this privilege. Other guests/siblings must remain in the waiting area accompanied by an adult.

We request that 24-hour notice be given if you cannot bring your child for their scheduled appointment. You will be charged a $25.00 fee for broken appointments when illness is not a factor and 24-hour notice is not given. I have read and fully understand the above Appointment and Cancellation Policy and accept all provisions.
*
- I have read and fully understand the above Appointment and Cancellation Policy and accept all provisions.
Parent or Legal Guardian Signature*
Consent for Dental Treatment

I request and authorize Dr. Jay Crews to examine, clean, and provide dental treatment on my child's teeth including but not limited to the use of local anesthetic and/or nitrous oxide ("laughing gas"). I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Crews to diagnose and/or treat my child's dental problem. I will allow photographs to be taken of my child or child's teeth for diagnostic or education purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Crews will provide an environment likely to help children to learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. I will be responsible for any charges incurred on this child for dental treatment.
Parent or Legal Guardian Signature*

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New Patient Form

Step 1 of 6

Patient Safety

Photography/Videography

Treatment Areas

Medical and Dental History

Treatment Authorization / Financial Agreement

Appointment and Cancellation Policy

Consent for Dental Treatment