We are Excited that You Chose Us!
Our goal is to serve you through the entire process. To that end we have developed some policies and documents that we feel will help guide you and us as we care for your child.
To Better Serve You and Your Children…
We need to work with accurate health and other information from you. To speed up your first visit with us, please print the policies and documents below, fill out completely, and sign before coming to your appointment.
- Office Policy — please review and sign printable version
- Acknowledgement of Receipt of Notice of Privacy Practices — please sign (.pdf opens in new tab)
- Parent Guidelines — please review and sign printable version
- Assignment of Benefits / Release of Information — please complete in detail (.pdf opens in new tab)
- Patient Information — please complete in detail (.pdf opens in new tab)
- Practice Terminology — please retain for your records
Please Bring Your Dental Insurance Card to Your First Appointment
** Please note it is your responsibility to know if your child has ACTIVE coverage through the Mississippi Medicaid and Mississippi CHIP insurance programs. **
For your first visit (and to expedite the process), please have all the following with you:
- Signed/dated Office Policy
- Signed/dated Parent Guidelines
- Signed/dated Acknowledgment of Receipt of Notice of Privacy Practice
- Filled-out and signed/dated Assignment of Benefits / Release of Information
- Filled-out and signed/dated Patient Information
- Dental insurance card (if applicable)