Patient Forms

Help us get to know your child!

Please take a moment and fill out our online patient information forms. If you have any questions along the way, feel free to contact our practice. We look forward to meeting you and your child at your first appointment.

Patient Info and Policy Forms

Attendance Policy

Broken/Missed Appointments
Your child's scheduled appointment is reserved specifically for them. We try to remind patients by telephone prior to the appointment, but please do not depend on this courtesy. If a cancellation is unavoidable, please call the office at least 1 business day (24 hours) in advance so that we may give your child's appointment time to another patient. If you do not cancel your child's appointment with more than 24 hours notice or if you do not bring your child to the appointment, we will consider this to be a broken/missed appointment. If 2 broken appointments occur, our office reserves the right not to schedule any subsequent appointments for your child. If multiple children were scheduled on the same day and an appointment was broken, we reserve the right to schedule only one child per day.
Occasionally, children's illnesses or other unexpected emergencies make it necessary to cancel an appointment with less than 24 hours of notice. Please contact our office immediately and we will do our best to accommodate your situation.

Late Arrivals
If you arrive more than 10 minutes late for your child's appointment, you may be asked to reschedule for the next available appointment time. Again, please call at least 1 business day (24 hours) in advance if a cancellation is unavoidable.

Broken Appointment/ "No Show" Fee
Missed appointments are an inconvenience to patients who need access to dental care in a timely manner; is inconsiderate to our doctor and team who are left sitting idle. Last minute/late cancellations are considered ‘no- show' appointments. We reserve the right to charge for any appointment(s) broken without 24 hours' notice. The charge will be $25.  These fees are not covered by insurance and are the sole responsibility of the patient. Fees must be paid in full prior to the patient's next appointment. 

Appointment Delays
We strive to see all patients on time for their scheduled appointment. We make every effort to stay on schedule. Additionally, there are times when our schedule is delayed in order to accommodate an injured child or an emergency. Please accept our apology in advance should this occur during your child's appointment. We will provide you the same courtesy if your child is in need of emergency treatment. We ask that if your child is not called back in a timely fashion, to please notify a staff member.
A parent or legal guardian (with official documentation) must be present in the office during the initial examination and/or any restorative appointments.
For the safety and privacy of all patients, other children who are not being treated should remain in the reception room with a supervising adult.

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(479) 326-7551
880 E Centerton Blvd
Centerton, AR 72719