Patient Forms

For your convenience, we have provided our patient forms online. We invite you to fill them out before your child’s appointment with Dr. Courtney Uselton and associates. This will save you time in our office and make your experience much smoother. If you have questions about our patient forms or about pediatric dentistry in Pittsburgh and McMurray, Pennsylvania, please contact Pediatric Dentistry South today. We will be happy to help you.

New Patients
Dear Parent:
We welcome you and your child to our practice. A full range of dental services is offered for children through adolescents to the age of 21. Recognizing that our office represents a new experience for you and your child, we offer the following information about our office. The American Academy of Pediatric Dentistry recommends the first infant dental examination by 12 months of age. Many problems that might otherwise develop can be prevented. The dentist, at the initial examination, will determine subsequent appointments. Generally; examinations, cleanings and fluoride treatments begin at 2 1/2 to 3 years of age. We are deeply committed to the total dental health and well-being of your child and to the ideals of preventive dentistry, from early home oral hygiene and control of carbohydrates to topical fluoride treatments and sealants.

BEFORE THE FIRST VISIT
You can play a large part in preparing your child for his/her visit to the dentist. Try to be relaxed. Your child will probably sense any anxiety on your part. Tell your child that we will “count” his/her teeth and then will show you both how to clean the teeth. Don’t use words such as “hurt, drill, shot, pull or needle.” Avoid statements like “the doctor won’t hurt you”.
Kindly complete all of the new patient forms under the forms section and submit to the office before your child’s first appointment.

THE FIRST VISIT
For that very first visit we ask that you come to our office 15 minutes early so that we can be sure we have all required paperwork completed. That extra time allows for us to make sure we are getting you registered before the appointment starts. This way you are ready to be present for your child’s first appointment, and your child has had a calm introduction into our practice environment.

Pediatric Dentistry South requires a parent or confirmed guardian, with guardianship documentation, be present for the first appointment.

We will thoroughly explain each procedure to the patient in terms he/she can understand before we do it. One person may accompany the patient into the treatment room to introduce the office and ourselves. To enable us to give the patient our full attention and to have his/hers as well, we may ask you to return to the reception room during treatment. If you would like to be present for your child’s appointment, we ask that you please keep your cell phone put away or completely off. If you would like to take one photo of your child during their visit please speak to their hygienist at the time. For your child’s privacy and the privacy of others we ask for the picture to be of just them. Please do not be upset if your child cries. Children are often afraid of anything new and strange, and crying is the normal reaction to that fear. At this visit, we will emphasize oral hygiene techniques to be practiced by both you and your child. Depending on need, diagnostic x-rays may be taken. Should any additional work be required, additional appointments will be scheduled. We suggest placing your child on a six-month periodic preventive appointment schedule. You may make that appointment then or you will receive a reminder when your child’s 6-month oral exam and cleaning is due.

FUTURE APPOINTMENTS
During future appointments we suggest that you remain in the reception room while we are working with your child. Though parents are regularly in or out of the treatment area, we find we can establish a direct and close rapport more quickly with your child when you are not present. However, if you choose, one adult may come with your child to the treatment room. For the safety and privacy of all patients, other adults or children not seen at this appointment should remain in the reception room. Please call in advance to set up an appointment. Please be advised that we may want to schedule patients at a time when the office is quieter, morning or early afternoon. If you cannot keep an appointment, please notify the office as soon as possible. This courtesy on your part makes it possible for another patient to be seen at that time. It is our policy to charge a fee for an appointment for which we were not given 24-hour notice of cancellation. An answering service answers the phone 24 hours a day. If there is an emergency, the service will notify the qualified dentist who is taking the calls.

PAYMENT
For our patients without dental coverage, payment is requested at each appointment as service is rendered unless other payment arrangements have been made. Payment can be made by cash, check, or credit card. As a courtesy for those who have dental insurance, we will submit the claim to your insurance company. Due to ever changing coverage, it is your responsibility to check with your insurance carrier for participation and coverage. If your insurance company has not paid in 30 days, you should contact your insurance company to check on the status of the claim. Please notify us immediately upon contacting your insurance company or if there is anything we can do to help settle the claim.

Policies
To provide a safer environment for our patients, and to ensure that the care we provide is in line with the Pediatric Medical Society, the AAP and the CCDC, Pediatric Dentistry South, Inc. (the “Practice”) is implementing the following policies and procedures regarding vaccinations. Effective September 1, 2018, we will no longer accept patients who have not received all vaccinations recommended by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the
American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. The only exception to this policy will be for patients who provide a valid and documented medical reason for not receiving the recommended vaccinations.
Please visit our FIRST LOOK section to have a “LOOK BOOK” view of our office.

Please open and complete the following forms as instructed by the office. After filling out the entire form, hit the SUBMIT button to have the form sent to our office electronically.

  1. New Patient Welcome
  2. HIPAA Agreement Form
  3. Medical History and Consent Form
  4. Financial Responsibility Form
  5. Privacy Notice
  6. Patient Information Form
  7. Medical History Update (Existing Patients Only)
  8. Nitrous Oxide Information
  9. Nitrous Consent
  10. IV Sedation Form
  11. Southwestern Ambulatory Surgery Center Patient Forms
  12. Southwestern Ambulatory Surgery Center Patient Information
  13. Anesthesia and You