(207) 781-2272(207) 781-2272
Great smiles start here!

We thank you for choosing Falmouth Pediatric Dentistry.

Please fill out the form below. Any missing or incomplete information may require us to reschedule your child's appointment.

You must also bring a valid Photo ID, as well as complete insurance information. In addition, a parent or legal guardian must be present at the first appointment.

Please feel free to write down any questions that you may have so we may discuss them with you.

If your child was referred to us, we have scheduled a "get acquainted" appointment so we can get to know you and your child, do an examination, and discuss a treatment plan for your child. If your child needs to return for restorative work at our office, we will provide you with an estimate.

We aim to develop a strong bond with your child—a relationship that will lead to good oral health. We encourage parental involvement, and want you to be aware of your child's oral health.

For cleaning appointments, we welcome parents in the room so that we can discuss any challenges you may encounter with home care and get to know your family. For restorative appointments, we find that children do best when we have their undivided attention, so we ask that parents remain in the waiting room. We are always happy to discuss this philosophy with you in person if you have any questions.

As a courtesy, we will prepare and submit your insurance claim forms. Please provide us with an insurance card showing proof of dental insurance coverage.

Please call our office if you require any additional information before your next appointment. We look forward to seeing you soon.

There was a problem with your submission. Please correct the issues below

Patient Registration

Insurance Information

I consent to the diagnostic procedures and treatment by Falmouth Pediatric Dentistry necessary for proper care of my child(ren). I consent to the use and disclosure of my child's records to carry out treatment, to obtain payment and for those activities and healthcare operations that are related to treatment and payment in keeping with HIPAA regulations. My consent to the disclosure of records shall be effective until I revoke such in writing. I authorize payment directly to Falmouth Pediatric Dentistry of insurance otherwise payable to me. I understand that my dental insurance carrier or payor of my dental benefits may pay less than the amount billed for services and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous statements lo the contrary and agree to be responsible for payment of services not paid by my dental care payor. 

I attest to the accuracy of the information on this page.

Dental History

Health History

I certify the above information is complete and accurate to the best of my knowledge.

Office Policies

  • A parent or legal guardian must be present for the first visit.
  • While we highly encourage parents to attend every visit, we understand the need for family members to help out. If a family member is bringing your child, they must bring a note declaring that the family member is allowed to bring the patient. Any treatments under the care of this family member are still your financial responsibility.
  • Please bring a picture identification card with you to each visit. If we are unable to identify you, you will be asked to reschedule.
  • Please verify your current dental insurance prior lo dental visits. While we submit claims to insurance companies, we are not in-network with any insurance company other than Delta Dental. We do not accept HMO insurance plans.
  • We require 48 hours notice to cancel or change any appointment.
  • We allow one failed appointment, after that your family will be dismissed from the practice.
  • Please arrive 10 minutes before your appointment start time. This allows ample time to update your information and ensure a smooth check-out process.
  • If you arrive 10 minutes past your appointment time, you will be asked to reschedule. We will do our best lo reschedule your appointment to the next available time slot.
  • While we do allow parents in the room for cleanings, we do not allow parents in operatory rooms during dental restorations.
  • Co-payments are due in full at the time of service. Pre-treatment estimates will be sent to your insurance company to determine your out of pocket cost for dental restorations. While we make every attempt to work with your insurance company and provide an accurate estimate, it is only an estimate.
  • Any balance due musl be paid within 30 days of receiving a bill or the account. After 30 days a 1.5% per month finance charge will be assessed. Balances that are unpaid after 90 days will be turned over to a collection agency and charged an additional 40% collection fee
  • As this is a pediatric practice, we ask that you use age appropriate language in all areas of the office. Anyone violating this policy will be asked to leave.

I have read, understood, and agree to the above listed policies.

Privacy Practices

Federal and state law requires us to maintain the privacy of your health information. That law also requires us to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices we describe in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such applicable law permits the changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. 

DOWNLOAD PRIVACY PRACTICES NOTICE

I acknowledge that I have downloaded a notice a Notice of Privacy Practices from Falmouth Pediatric Dentistry.

If a personal representative signs this authorization on behalf of the individual, complete the following:

COVID-19 Pandemic Dental Treatment Consent & Waiver Form

I knowingly and willingly consent to have dental treatment of my child, completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

Dental procedures create water spray. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

  • I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I may have an elevated risk of contracting the virus simply by being in a dental office.
  • I have been made aware of the CDC, ODA, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. 
  • I confirm I am seeking treatment for my child for a condition that meets these criteria.

I confirm that my Child, my immediate family members, and I are not presenting any of the following symptoms of COVID-19 listed below:

  • Fever
  • Shortness of Breath
  • Dry Cough
  • Runny Nose
  • Sore Throat
  • Loss of Smell
  • Loss of Taste

I also understand that the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has traveled recently, and this is not possible with dentistry.

  • I verify that my Child and I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.
  • I verify that my Child and I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.

On behalf of my Child and myself, I waive and release any and all claims, causes of action of any kind, and damages against Falmouth Pediatric Dentistry PC (and its shareholders, officers, employees, agents, including Dr. John Willis) which relate to the COVID-19 epidemic or health effects of the COVID-19 virus, and which arise at any time.

I represent and confirm that I am the parent and legal guardian of the Child and I am acting in such capacity in executing this Consent and Waiver form on behalf of my Child. 

This Consent and Waiver shall be governed by the laws of the State of Maine.

Please check the box below before submitting.

* REQUIRED FIELDS