Patient Forms


The following forms are provided for you to download in preparation of your child’s visit to Raleigh Pediatric Dentistry or Rolesville Pediatric Dentistry. Please print out a copy, read carefully, and fill out all appropriate forms (*) prior to your child’s visit. If you have any questions or concerns, do not hesitate to call us at (919) 845-8212. Thank you for choosing our office¬†for your child’s dental care.

These forms are in PDF format. If you do not already have a PDF reader, please click here to download a free reader

New Patient Forms
Parent Letter
Health History *
General Consent Form *
Appointment Policy
Children, Pediatric Dentistry and You
Financial Policy *
Credit Card Authorization *
Payment Policy
Safety and Privacy
Questionaire for Parents of Patients with Special Needs * if your child has special heathcare needs.
Questionaire for Parents of a Patient with Autism

Other Forms
Parent Satisfaction Form