DOWNLOAD FORMS

For your convenience, please download and complete the forms prior to your office visit.

MEDICAL HISTORY

REQUIRED
AT CHECK-IN
  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Complete answers will expedite the office visit.

FINANCIAL POLICY

REQUIRED
AT CHECK-IN
  • The ultimate goal of Missoula Pediatric Dentistry, as outlined in our mission statement, is to provide quality care and be understanding of all our patients. We feel confident in our ability to provide you and your child valuable dental care which will exceed all your expectations. Our desire is to establish a long-lasting relationship with you and your child.

CONSENT TO RECEIVE PHONE CALLS

RECOMMENDED
AT CHECK-IN
  • In accordance with The Telephone Consumer Protection Act of 1991 (TCPA) and Health Insurance Portability and Accountability Act (HIPPA), we may send you information including protected health care information, demographic or billing information that may individually identify you or the patient and that relates to past, present, or future health conditions and related health care services and payment or for the purpose of treatment and billing.

BEHAVIOR MANAGEMENT TECHNIQUES

REQUIRED
AT CHECK-IN
  • We do our best to give your child the best quality dental care in a safe and caring environment. Every effort will be made to work with your child to gain cooperation through understanding, gentle guidance, humor and charm. When these fail there are other management techniques that can be used to eliminate or minimize disruptive behavior. Please review the following techniques.

PRIVACY PRACTICES

REQUIRED
AT CHECK-IN
  • This Notice described how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

MEDICAID PATIENTS ONLY

REQUIRED
AT CHECK-IN
  • I understand that my child's continued dental treatment depends on me! I also understand and agree to the following conditions: I must have my child's Medicaid enrollment card at every visit, failure to present this card to verify eligibility at every visit will result in not being seen and this is considered a failed appointment.

SCHEDULE AN APPOINTMENT!

We invite you to be present with your child during all of their visits to our practice.