For New Patients

Our days are better and brighter when we get the opportunity to meet new patients and their families!  We try to do everything we can to make you feel most welcome.

So your first visit can be more fun and less bogged down with paperwork, we've made our New Patient Forms available here.  

All you have to do is fill them out prior to your first visit and send them to us via the website.  It's that simple and you will be ready to go when you arrive!  If you have any questions, don't hesitate to call.

Our office hours are: Mondays 8-5, Tuesdays 8-5, Wednesdays 7-12 and 1-5, Thursdays 8-5, and Fridays 8-1.

Our office address is 9126 Technology Lane, Ste 100 in Fishers, Indiana.  We are located behind the Super Target at 116th Street and I-69.  We are neighbors to the Fieldhouse sports facility.  Come see us!!!!

Also, if we can assist you in any way by answering questions about our office, procedures, scheduling, etc., or if you'd like to discuss procedures for special needs children or adult handicapped patients, please call us at 317-598-9898 and ask for Charity.

To meet our INCREDIBLE, COLORFUL, and OUTSTANDING staff, click here!

New Patient Forms

Please, fill these out only AFTER you schedule your appointment with us!  Call 317-598-9898 to make an appointment.

Tell Us About Your Child

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First Name *	Last Name *

Date of Birth *	Sex *
	Male Female

Address *

City *	State *	Zip *
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Phone *	Nickname

School	Grade

Who is Accompanying the Child Today?

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First Name	Last Name	Relation

Do you have legal custody of this child?     Yes     No

Is the child adopted?     Yes     No

Is the child in a foster home?     Yes     No

Whom may we thank for referring you?

Other sibling(s) seen by us?

Parent's Marital Status

Married    Divorced    Separated

Widowed    ReMarried    Single

Mother's Information

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Address is same as Child

First Name	Last Name	Home Phone

Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Social Security #	Date of Birth

Employer	Work Phone #
Email

Father's Information

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Address is same as Child

First Name	Last Name	Home Phone

Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Social Security #	Date of Birth

Employer	Work Phone #
Email

Insurance Information

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   PRIMARY COVERAGE

Dental? Yes  No	Orthodontic? Yes  No

Name of Insured	Relation to Child

Social Security # of Insured	Date of Birth

Employer Name

Employer Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Insurance Co. Name	Phone #

Insurance Co. Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Group I.D. #

   SECONDARY COVERAGE

Dental? Yes  No	Orthodontic? Yes  No

Name of Insured	Relation to Child

Social Security # of Insured	Date of Birth

Employer Name

Employer Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Insurance Co. Name	Phone #

Insurance Co. Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Group I.D. #

Dental History

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What is the primary reason for today's visit?

Is the Child in pain? Yes  No

Previous/Present Dentist	Last visit	Last x-rays

Why did you leave your previous Dentist?

What did you like the most about your previous Dentist?

What did you like the least about your previous Dentist?

Was the previous dental experience positive or negative?

Is the primary source of water consumed fouridated?

Yes  No

Was the Child breastfed, bottlefed or both?

Breastfed  Bottlefed  Both

Breastfed	Bottlefed
Until what age?

How often does your child brush their teeth?

Once Daily  Twice Daily

How often does your child floss their teeth?

Once Daily  Twice Daily

Does your Child...

Bite/Chew Nails?  Yes  No

Bottle Feed Currently?  Yes  No

Breast Feed Currently?  Yes  No

Clench/Grind Teeth?  Yes  No

Have Speech Problems or Impairment?  Yes  No

Mouth Breathe?  Yes  No

Suck/Bite Lips?  Yes  No

Suck Thumb/Finger?  Yes  No

Tongue/Cheek Chew?  Yes  No

Tongue Thrust?  Yes  No

Use Pacifier?  Yes  No

Medical History

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Are Immunizations Current?  Yes  No

Child's Physician	Phone	Last Seen

Address

City	State	Zip
	--Select-- ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Is the Child currently under the care of a physician?

Yes  No

Please explain

List all medications that your Child is currently taking

List all drug allergies and/or reactions

Has the Child had the following...

Abnormal Bleeding?  Yes  No

AIDS/HIV+?  Yes  No

Allergies?  Yes  No

Anemia?  Yes  No

Asthma?  Yes  No

Blood Transfusions?  Yes  No

Cancer?  Yes  No

Cerebal Palsy?  Yes  No

Congenital Heart Defect?  Yes  No

Convulsions?  Yes  No

Cystic Fibrosis?  Yes  No

Diabetes?  Yes  No

Eating Disorder?  Yes  No

Epilepsy?  Yes  No

Hearing Impairment?  Yes  No

Heart Murmur?  Yes  No

Hemophilia?  Yes  No

Hepatitis A, B, C?  Yes  No

Hives?  Yes  No

Hospital Stays/Operations?  Yes  No

Kidney Problems?  Yes  No

Liver Problems?  Yes  No

Sickle Cell, Camer or Trait?  Yes  No

Tonsilitis?  Yes  No

Tuberculosis?  Yes  No

Financial Policy

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PAYMENT IS DUE AT THE TIME OF SERVICE - The full balance of treatment is due at the time service is rendered. Payment plans are not available from our office. For your convenience we accept cash, check, Care Credit, Master Card, Visa and Discover. Assignment of Dental Insurance Benefits - Our office files insurance benefits as a courtesy. Claims upaid by your insurance co. after 60 days are your responsibility and will be due in full. All deductibles co-payments, and no-covered fees are due at the time of service. A CURRENT copy of your insurance card must be kept on file to utilize this service. Our office reserves the right to discontinue and/or refuse to file claims. Service Charges - A rebilling fee of $5.00 may be applied to accounts with balances unpaid within 30 days of the statement date. A $30.00 fee will apply to all returned checks. Our office reserves the right to pursue any other remedy by law. Delinquent Accounts - Account balances that exceed 90 days may be pursed through a third party collections. All reasonable expenses incurred in the collection process will be the account holder's responsibility.

How will you be paying?   Cash Check Master Card Visa Discover Care Credit

Authorizations

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I affirm that the information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in my child's medical status. I authorize the dental staff to perform all necessary dental treatment my child may need. I authorize the release of all information necessary to secure benefits otherwise payable to me. I understand that I am responsible for the full balance of the account regardless of my dental benefits. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. I affirm that my signature represents my agreement to all the above mentioned terms.