Patient Forms

Help us get to know your child!

Please take a moment and fill out our patient information form before your appointment at our Winston-Salem or Kernersville office. If you have any questions along the way, feel free to contact our practice.

Paper-less option

Online New Patient Form

If you would like to fill-out and submit our paperwork online, simply email and we will send a digital copy of all necessary documents.  

Paperwork to print and fill out at home

  • New Patient Form PDF 
  • Dental Cleaning Form PDF | DOCX
  • COVID-19 Screening Form PDF | DOCX
  • HIPAA Form PDF | DOC
  • Authorization to Release Information Form PDF | DOCX

We look forward to seeing you!

Thank you for taking the time to fill out your paperwork ahead of time.  We look forward to seeing you at your next visit!

Dr. Gina Spangler
Dr. Gail Rohlfing
Dr. Kate Lambert
Dr. Kelly Lipp
& The Pediatric Dental Team