New Pediatric Patient Registration Form

Pediatric Registration Packet

Thank you for choosing
our office for your dental needs. We look forward to meeting and working with
you! Jack and Jill Pediatric Dentistry is a professional and comprehensive dental care
practice focused on building a foundation of trust by treating our patients of
all ages with the utmost care. Our commitment is to ensure that you and your
family feel welcomed, informed, and comfortable. Our key philosophy is prevention,
and our team works hard to provide state of the art treatment, while taking the
time to educate our patients about preventive care.

This initial
registration packet is for us to get to know you, to help address your
concerns, and your needs, get you processed into our system, and then continue
on with the dental treatment and services as needed. If you have any questions
please feel free to ask our front desk staff.
We will be happy to help


To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical history.
Please upload a copy of your insurance card: (If you are using a phone or tablet and have camera access, you can upload directly from the phone by selecting \"Choose\" or \"Browse\"