Patient forms

New Smiles Damascus

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

New Patients Individual forms if needed:
Patient information form
Medical/Dental History form
HIPPAA consent  & Financial agreement form
COVID screening form

Location/Building facade New Smiles Frederick

Existing patients coming to appointment
Info Update, COVID screening form 
Informed Consent form
Non-parent consent form

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.