HH Update Form

Information Update Form
Welcome back to our practice! This is our information update form. This is usually required when we haven't seen a patient in a year. We need to remain up-to-date with the patient's information so we may best serve them.

This will take 3-5 minutes of your time. Please fill it out as comprehensively as possible.
Which department of Let's Smile™ Dental do you have an appointment with?*
General Information
Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Are you receiving text/email reminders of your appointments with our office?*

YesNo, and I would like to continue to opt out of text/email remindersNo, and I would like to opt in to receiving text/email reminders

Let's Smile™ Dental Policy Reminders
Cancellation Policy

I acknowledge that I will be responsible for the fees that follow for a broken or no-show appointment if the 24-hour prior cancellation notice is not given.

Fees
- $50 Pediatric / Orthodontic Routine Appointment
- $75 Restorative
- $100 Oral Sedation
- $200 General Anesthesia
Signature of Responsible Party*

Clear
Photo Release Form

I hereby grant permission to Let's Smile, PC to use my/my child's photograph and/or video in any marketing, advertising, or teaching materials used to market or advertise the practice, including use on their website and/or social media sites.

I acknowledge the practice's right to crop or otherwise treat the photograph or video at their discretion. I also acknowledge that the practice may choose not to use my photograph and/or video now but may do so at their discretion later.

I also understand that once my image is posted on the website, the image can be downloaded by any computer user, which is beyond the control of the practice. I will hold the practice and any affiliated offices harmless from any such use or download.
Please make a selection*
Signature of Responsible Party*

Clear

This only needs to be completed if the patient in under 18 years of age.
Parental Consent Form

Note: At Let’s Smile™ Dental, we value and appreciate our patients as well as their parents and guardians. To keep our workflow as efficient and as safe as possible, we have updated our policies with regards to who may bring a patient for an appointment:

•       If a child under the age of 18 presents by themselves without the parent or legal guardian, we will have to reschedule their appointment. Phone calls will not be accepted as confirmation of parental supervision.

•       If a parent or guardian is unable to be present at the time of the appointment, you may have an individual that is 18 years or older accompany your child if they are listed below, OR have filled out the parental consent form in-practice.

•       For new patient appointments, the legal parent or guardian must be present at the first appointment.
Please list all children below:
Authorized Caregiver's Name:

First NameLast Name
Relationship to Children:
Caregiver's Phone Number:
Please enter a valid phone number.
By signing below, I give permission for the above name caregiver to be authorized to accompany the abovenamed child(ren) for their orthodontic appointments and subsequent recall visits. Treatment to be performed includes routine orthodontic services outlined during the initial consultation appointment. The initial patient registration package, all medical history/dental history must be filled out by parent or legal guardian. This consent shall be effective from date of signature until revoked by parent or legal guardian.
Parent / Guardian Full Name:

First NameLast Name
Parent / Guardian Signature:

Clear
Should be Empty:

Information Update Form

General Information

Medical/Dental Information

Let's Smile™ Dental Policy Reminders