All patient forms can be requested from our office as an online form and completed securely via your mobile device. Call or message us to request the online forms.
If you choose to use paper, simply print & complete the forms below.
New Patient Packet (pdf)
DownloadAuthorization for Release of Dental Records (pdf)
DownloadNotice of Privacy Practices-HIPAA (pdf)
DownloadOVER 18 years old Medical History Packet (pdf)
DownloadMedical History UPDATE: established patients only (pdf)
DownloadGuardian Authorization Form (Consent to Treatment Without a Parent/Legal Guardian Present) (pdf)
DownloadNitrous Oxide (laughing gas) Consent Form (pdf)
DownloadTooth Extraction Consent Form (pdf)
DownloadSilver Diamine Fluoride (SDF) Consent Form (pdf)
DownloadAbscess & Cellulitis Information for Parents (pdf)
DownloadInformed Refusal of Xrays (pdf)
DownloadFilling Information for Parents (pdf)
DownloadAltus
Ameriplan
Ameritas
Assurant
BCBS/Freedom Blue/FEP
Cigna
Delta Dental Premier
Guardian
Harvard Pilgrim (not pediatric)
Principal
Aetna
Delta Dental PPO
Dentemax
Harvard Pilgrim Pediatric
Metlife
Total Choice
Tricare
United Health Care
United Condordia
Aetna DMO
Cigna DMO
Delta Care
Delta Dental EPO
Delta Dental Health Connector
Delta Plans Associated with MassHealth: MassHealth, Unicare, Children's Health Network
Fallon
Health Net
Neighborhood Health
Tufts Health Connector
Tufts
If you have a different dental insurance policy, you will be responsible for paying for services, and we can provide you the necessary forms to submit to your insurance company. If you do not have dental insurance, you will be responsible for all procedure costs due at each visit.
The primary goal of Duxbury Children's Dentistry is to provide quality dental care for your child. Inherent in our relationship with your child is a financial relationship with you as the child's parent/guardian.
Duxbury Children's Dentistry
95 Tremont Street-Suite 18, Duxbury, MA 02332
Tel. 781-934-7111 Fax. 781-934-7125
COPYRIGHT © 2024 DUXBURY CHILDREN'S DENTISTRY, LLC