Forms

Welcome to Kind Kids Dental!

We’re excited to welcome new patients into our pediatric dental family! To help us get to know your child and provide the best possible care from the very first visit, we invite you to complete the necessary forms ahead of time. This makes check-in smooth and easy so you and your little one can relax and focus on enjoying a positive, comfortable experience with our team. We can’t wait to meet you!

New patient forms

Choose how to complete our forms: Click the Patient Registration Form button below to complete the form online, OR, download via the download icons below, fill out in Acrobat, and either email completed forms to info@kindkidsdental.com or bring in completed forms with you to your appointment.

Thank you!

Patient Registration Form

Download New Patient Registration

Please take a moment to fill out the registration forms before your first appointment. Click the link above to download.

Download Code of Conduct

Records Release/Transfer Form

Choose how to complete our forms: Click the Release of Records Form button below to complete the form online, OR, download via the download icons below, fill out in Acrobat, and either email completed forms to info@kindkidsdental.com or bring in completed forms with you to your appointment.

Thank you!

Release of Records Form

Download Release of Records Form

Transfer records to or from Kind Kids Dental. Click the link above to download.

Medical History Update Form

Choose how to complete our forms: Click the Medical History Update Form button below to complete the form online, OR, download via the download icons below, fill out in Acrobat, and either email completed forms to info@kindkidsdental.com or bring in completed forms with you to your appointment.

Thank you!

Medical History Update Form

Download Medical History Update Form

Update your child's medical history for our records. Click the link above, download, print, and bring the completed form with you.

Referral Form

Choose how to complete our forms: Click the Referral Form button below to complete the form online, OR, download via the download icons below, fill out in Acrobat, and email completed form to info@kindkidsdental.com.

Thank you!

Referral Form

Download Referral Form

Refer a patient to Kind Kids Dental. Click the link above to download and complete our referral form.

Request an appointment

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Parent Name *

First

Last

Patient's Name *

First

Last

Child's age *

Is your child a current patient? *

Names and ages of additional children needing an appointment

How would you prefer to be reached? *

Phone call
Text
Email

Phone Number *

Child's current a

Email *

Type of appointment *

New patient
Cleaning
Second opinion
Other

Preferred day *

Monday
Tuesday
Wednesday
Thursday

Preferred time of day *

Morning
Afternoon

Comment or Message

“Dr. Kasey and his staff are absolutely amazing! I have a child with special needs and they are so fantastic with making sure everything is just the way he needs it. Plus they are so so patient and sweet with my toddler. I highly recommend this dental practice. My kids love going because of how great they are!”

-Sam D.