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

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 for 1-3 year olds PDF 
  • New Patient Form for 4-12 year olds PDF
  • New Patient Form for 13 years and older PDF  
  • Dental Cleaning Form PDF
  • HIPAA and Practice Policies Form PDF
  • Authorization to Release Information Form PDF

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
Dr. Angela Baechtold
& The Pediatric Dental Team