Patient Forms

Thank you for choosing Canton Pediatric Dentistry. Please complete the forms below prior to your child’s appointment. If you experience any problems accessing the forms, please contact our office so we may assist you in obtaining them prior to your visit. We look forward to seeing you soon!

• Medical History Form  
• Download Acknowledgements  

Appointment Policy

A specific timeframe is allotted for your child according to his or her treatment needs. As a courtesy, Canton Pediatric Dentistry will attempt to contact you to confirm the appointment time; however, we ask that you assume responsibility for your child’s appointed time.

We request a 24-hour notice to cancel or reschedule an appointment, so we may offer that time to another patient. Multiple broken/missed appointments without a 24-hour notice of cancellation may be subject to dismissal from the practice.

Financial Policy

Fees incurred for dental services are due in full when services are rendered. For your convenience, we accept cash, personal checks, MasterCard, Visa, and Discover.

Insurance

As a courtesy, we will file your dental insurance on your behalf and accept assignment of payment. Please note that your insurance company will verify your dental benefits and dentist of choice; however, most plans only cover a portion of the dental fee incurred.

In addition, some insurance companies recommend a pre-treatment authorization for the dental treatment to be provided. We will attempt to estimate expenses prior to your visit to our office; however, please be prepared for any deductible, co-pay, or other expenses in excess of the estimates at the time of service, if necessary.

If, for any reason, your insurance company does not respond with financial payment within 45 days post treatment, the balance is due and payable in full immediately by the responsible financial party.

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