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Easley
Greenville
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About Us
About Ashby Park Pediatric Dentistry
Reviews
Careers
Request Appointment
Dentists
Dental Services
Dental Crowns
Dental Fillings
Dental Sealants
Dental X-Rays
Fluoride Treatments
Oral Health Exams
Oral Surgery
Pulpotomies / Root Canals
Sedation Dentistry
Sports Mouthguards
Teeth Cleanings
Tooth Removals (Dental Extractions)
Parents
Your First Visit
Patient Form
Emergencies
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Locations
Easley
Greenville
Contact Us
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Personal Intake Form
Are you in the Office or at Home?
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Easley
Greenville
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Add child/children you’re completing this intake form for?
I am the Legal Guardian for the children named below:
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Please list below any individual that can bring your child(ren) to their appointments. By listing their name you are also consenting to give this individual(s) permission to receive information, the right to sign the medical history and consent to routine dental treatment.
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Please read each statement and signify approval by checking the box beside it:
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I am certifying that the information listed is complete and accurate.
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I am the legal guardian of the children identified above.
I read and understand the Photo Release Form
I read and understand the
Photo Release Form
I consent
I decline
*
I have read and understand the
Privacy Act Document
.
*
I will be responsible for any fees not covered by my insurance company and have read and understand
Ashby Park Pediatric Insurance and Office Policies
.
Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate:
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