Patient Forms

If you have already scheduled a first visit, the new patient forms can be accessed through our Patient Portal here: 

Patient Portal

Download our new Patient Portal App by Modento!

This secure and HIPAA compliant app connects you with the office like nothing you’ve seen before.  Fill out forms, sign consents, fill in pre-populated medical history updates, personalized notifications, insurance updates, check-in from your car and direct text with the office… all from your mobile device or tablet.  We are moving paperless and this is just the first step.  Download today! Click here to download the app

Otherwise, 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

For Referring Doctors
Referral Form

Other Forms
Parent Satisfaction Form