Patient forms

New Smiles Damascus
Reception New Smiles Damascus

Damascus Patient forms

New Patient Forms- Complete set.
First time patients need to complete this set for each child in family.

New Smiles Frederick Reception
Location/Building facade New Smiles Frederick

Frederick Patient Forms

New Patient forms – Complete Set.
First time patients need to complete patient, emergency contact, insurance, history, HIPAA tabs for each child in family.

Existing Patients Coming to Appointment
Info Update, COVID screening form
Please complete the patient and update tabs only. Unless Emergency contact info or Insurance has changed then complete those tabs too.
Non-parent consent form
If child will be brought to the appointment by Guardian/Grandparent/Elder sibling, then please complete patient tab and Non-parent consent tab. 

In case the webforms do not work for you. Below as a PDF file. You can print, fill and bring them along.

Medical History Form

If a Parent or Legal Guardian is not going to accompany the child, please print below form, sign, date, witness it and send along with caregiver to clinic on day of appointment.

NSKD non parent consent form only

Below are copies of our policies, acknowledgments and consents.

  1. Notice of Privacy Practices
  2. Notice of Non-discrimination
  3. Financial & Office Policies
  4. Billing of Non-covered services 
  5. Informed consent for treatment
  6. Image Release form
  7. Please read and understand the pre & post op instructions for moderate sedation.

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