Prep for Your Visit

Before arriving to your appointment, we ask a couple of favors from you to speed the process & make your trip convenient. Fill out our new patient form below.

Providing accessible, compassionate & effective dental care to Puget Sound children in need.

Prep for Your Visit

We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out this annual patient information form as completely as you can. If you have questions we will be glad to help you. We look forward to working with you in order to maintain your child’s dental health. Thank you!

MM slash DD slash YYYY
Name of Minor/Child
Sex
MM slash DD slash YYYY
Home Address
Mailing Address
Name of Parent/Guardian
Emergency Contact Name
By providing your email, you are giving LDCC permission to contact you via email. Contact will include, but is not limited to , appointment confirmations and reminders, treatment information, information regarding the clinics, LDCC newsletter, special events and other LDCC related communications. LDCC will not share your information.
Check if your referral came from MultiCare Health Systems
Consent
Name
Name
Name
MM slash DD slash YYYY

Dental Insurance Information

LDCC accepts WA Apple Health (Medicaid/Provider One), most private insurances, and offers a sliding fee scale. Below please indicate which option(s) apply to your child. Please check and provide information for all that apply.
WA Apple Health (Provider One)
Primary Private Insurance
Subscriber Name
MM slash DD slash YYYY
Address
Insurance Company Address
Secondary Private Insurance
Subscriber Name
MM slash DD slash YYYY
Subscriber Address
Insurance Company Address
Sliding Fee Scale

Dental Benefits Claim Information

We are pleased that many of you have dental benefits and our office will assist you in obtaining the maximum benefits specified in your contract. Your benefits are a contract between you, your employer and/or a carrier. We will assist you in determining your benefits as best we can. Because plans differ from carrier to carrier and policy to policy, our office many refer you to your carrier or your employer’s benefits coordinator for assistance in understanding your plan. As a courtesy to you, we will file your benefits claim and accept assignment of benefits. Not all services are covered benefits in all contracts. Some carriers and employers select only some services to be covered. You are responsible for payment of all services regardless of the payable benefits.
INSURANCE AND FINANCIAL POLICY
TREATMENT CONSENT
Name
MM slash DD slash YYYY

Policies Acknowledgement

Child's Name
MM slash DD slash YYYY

Appointment Policies

It is the goal of Lindquist Dental Clinic for Children (LDCC) to provide a positive dental experience for both the patient and the family. In order to provide the best care possible for all the children we serve, we must adhere to the following policies: Parents/Guardians Must Remain in the Clinic: Parents or Guardians of children with scheduled appointments must remain in the clinic at all times. This is very important because there are times that the providers may need to speak with you about your child’s care and we will not be able to proceed if you are not in clinic. Confirmation or/Cancellation of Appointment: We have many children in need of appointments at LDCC, it is imperative that appointments be confirmed, either via the text you receive or by phone. Failure to confirm could result in your child/children being rescheduled for a later date. If you need to cancel or reschedule your appointment it is imperative that you notify our office by 5 pm the day before your scheduled appointments. Late Arrivals: A late arrival is arriving any time after your scheduled appointment. If you arrive late for your appointment, you may find that your appointment may have been filled by another patient. You will be offered to wait on a standby basis for an opening that day or to reschedule your appointment. No-Show Policy: Your child’s appointment will be considered a “no show” for that appointment if we are not notified of your need to cancel the appointment by 5 pm day prior to your child’s appointment OR if you fail to show for your appointment. Patients with two (2) “no- show appointments within a rolling 12 month period will be ONLY be seen on standby status. Scheduling with Multiple Children: LDCC will schedule up to 3 children on the same day at our Parkland Clinic, as long as there are NO MISSED appointments. In our Bremerton Clinic, we will schedule 2 children on the same day, again with NO MISSED appointments. Additional children will be scheduled for another day or may be seen on stand-by schedule as available. Payment Policy: A minimum payment of 25% of the open balance or the family balance is due at time of service, OR you have current and up to date payment plan. DSHS patients must bring their Provider One card to insure current monthly eligibility. Private insurance patients must bring proof of insurance and pay their portion at each appointment, unless on an established and current payment plan. Your family may qualify for financial assistance for your patient portion. To apply for financial assistance you must complete the financial assistance form and provide proof of income. The amount of assistance is based on family size and annual gross income. Financial assistance must be renewed each calendar year.
Parent/Legal Guardian Name
MM slash DD slash YYYY

Photo Release

Child's Name
MM slash DD slash YYYY
Consent
Parent/Legal Guardian Name
MM slash DD slash YYYY

Acknowledgement of Receipt of Notice

Child’s Name
MM slash DD slash YYYY
Consent
Parent/Legal Guardian Name
MM slash DD slash YYYY