New Patient Information

Thank You for Selecting Us

Download (PDF)

Child's Information
Male Female



   Zip:





Do you already have an appointment?
Yes No


If No, Please call to Arrange an appointment.
PARENT OR GUARDIAN INFORMATION (MOTHER OR GUARDIAN)

(if different than child's)


   Zip:





PARENT OR GUARDIAN INFORMATION (FATHER OR GUARDIAN)

(if different than child's)


   Zip:





PRIMARY DENTAL INSURANCE








FINANCIAL ARRANGEMENTS

For your convenience we offer the following methods of payment. Please check the option you prefer. Payment in full is due at each appointment.

  • Cash
  • Personal Check
  • Visa
  • MasterCard

I authorize the dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my dependent's behalf. I agree to be responsible for all fees incurred in attempting to collect these fees.

 

 

< Back to Dental Glossary

Children's Dental Health Associates

5 office locations

For an evaluation of your child's teeth, give Children's Dental Health Associates, P.C. a call today at one of our 8 dental office locations serving western Philadelphia, PA suburbs of Drexel Hill, Newtown Square, Lansdowne, Media, Chadds Ford, Kennett Square, Jennersville/West Grove, Pennsbury, West Chester, Downingtown/Thorndale, Lancaster, and Aston PA.

In anticipation of an appointment, you can obtain new patient and medical history forms online.