Patient Forms and Information

New Patient Forms

Thank you for choosing The Pediatric Dentists to be your child’s dental care provider! Please fill out the following forms before your child’s first scheduled dental appointment.

Pediatric Dentistry Health History Contact Information and Financial Responsibility Payment Method / Dental Insurance Policy

– Notice of Privacy –

Acknowledgment of Receipt of Notice of Privacy Acts *Authorization for Agent to Consent to Dental Treatment of a Minor

*Consent form only needs to be completed if someone other than the legal parent/guardian is bringing the child/children to ANY type of dental appointment.

Existing Patients

6 Month Update Form

For existing patients, this form is to be completed every 6 months for routine care

Insurances

We gladly accept most insurances. We are also happy to provide services to those that are uninsured, underinsured, or have insurance that is out-of-network with our offices. Call our offices today for details and to schedule your child’s great experience!

Payment Options and Financing

For your convenience, we accept payments made with cash, Visa, MasterCard, and Discover.

Financing is also available through CareCredit. With CareCredit, you pay no up-front costs, no pre-payment penalties and no fees. Plus, CareCredit is a revolving credit line for additional care or add-on charges, without the need to re-apply. Use CareCredit’s Payment Calculator to compare plans and get an estimate of what your monthly payment will be.

It only takes a few minutes to apply for CareCredit and you may receive an online decision in seconds! Apply now or see our staff for more details.

Referring Providers

Office Referral Form

Palm Springs Location

490 S. Farrell Drive, Suite C-101
Palm Springs, CA, 92262
(760) 320-7621

Yucca Valley Location

7144 Airway Avenue,
Yucca Valley, CA 92284
(760) 365-4400