Patient Forms

Patient Forms:

If your child is a new patient at Middletown Pediatric Dental, welcome to our practice! At Middletown Pediatric Dental, we strive to provide comprehensive care for all infants, children, and adolescents. Our approach is simple – replace the anxiety and stress from dental office visits with care and personalized approach. At Middletown Pediatric Dental, we strive to be the dental home for your family, treating your child as what we would do for our own.

Prior to visiting our office please print and fill out your child’s new patient form and financial policy below. Please bring these forms in with you to your appointment, or email them ahead of time.

Dental Insurance:

Dental insurance often covers a portion of necessary dental treatment. However, the patient is also responsible for the remaining balances that insurance may not reimburse. Because we know budgeting and personal finances are important, we offer payment options for your essential dental care. As a courtesy to our patients, we verify insurance coverage benefits and provide estimates on coverage prior to the start of any treatment procedures. We will work closely with you to determine benefits as they apply to your treatment needs.

Our office accepts traditional payment methods such as:

  • Cash
  • Credit Card (VISA, DISCOVER, Master Card and American Express)
  • Debit Card
  • Personal Check

Treatment Financing:

Our office has also teamed up with a 3rd party financing company that offers credit to dental patients for their restorative or cosmetic dental procedures. CareCredit provides zero-interest flexible payment plans to our dental patients. To find out more information, or apply for credit online, visit their website:

CareCredit allows patients to make interest free payments over 12 months. The application is quick, and it makes treatment easier to complete when you need it, rather than delaying necessary treatment and possibly losing the tooth or needing a more expensive procedure later on.