Lahair and Gallagher Pediatric Dentistry Logo American Academy of Pediatric Dentistry

New Patient Forms:

New Patients, save time by printing out and completing the forms below before your first visit.

Medical/Dental History

Contact and Insurance Information

Financial Policy

Authorization to Release Information

Information Regarding Fillings

Privacy Policy

Privacy Acknowledgement Form

Financial Options

Co-payments are due at the time dental services are rendered.

For your convenience, we accept MasterCard, Visa, and Discover. We deliver the finest care at the most reasonable cost to our patients. If you have questions regarding your account, please contact us.


Insurance Options

We work with most companies to maximize your insurance reimbursement for covered procedures.

Please bring your insurance information with you to your initial exam or consultation so that we can expedite reimbursement.

Remember that the ultimate responsibility for understanding your policy is yours.