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Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Pediatric Dental Office Forms

Our administrative pediatric dentistry team is separate from our orthodontic administrative team.

For orthodontic office forms CLICK HERE.


Exciting News! Some appointments can now be scheduled directly by parents online!

For more information, see below or CLICK HERE.

Complete Forms Online Prior To Your Appointment

Our pediatric dental forms for new and existing patients can be completed online. For new patients, after you we review your submitted new patient registration form, we will contact you to schedule the first visit with our pediatric dental team. If you do not hear back from us by the end of the next business day, please contact the office.

Southern Smiles Dentistry

Pediatric Children's Dentistry New Patient Registration Forms

For new child patients prior to the first visit we:

  • Require completion of a new patient registration form

  • Create a dental chart for your child based on the information you submit

  • Review your child’s needs & dental history.

  • Then schedule the appointment and tailor it to your child’s needs.

Peds New Patient Reg Forms
Peds Patient Privacy Form
Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

To review our Patient Privacy Disclosure
& Acknowledgment Form in Advance
click on the title below.

X-Rays & Radiographs For New Patient Appointments

Sometimes your child may already have existing X- rays/radiographs from a previous dental home. Examples are: a bitewing, a periapical (abbreviated as PA), and a panorex. Having access to your child’s previous X-rays allows us to have a full picture of your child’s dental history. In the event you do not have a direct referral to us from your family dentist, please request a copy of your child’s X-rays from the dentist. A high-resolution copy emailed to you can then be forwarded to us. Please contact us here.

  • Please note that by law (NC Board of Dental Examiners), you are entitled to a copy of your X-rays from the family dentist or another orthodontist without having to sign a records release form, as long as they practice in the state of NC.

  • By law, you only need to verbally request (the law does not require you to be in person) a copy, and you can request that it be sent directly to us.

  • In the event that you are told that your or your child’s dental records won’t be released to you without a signed records release form, please understand that this is not legal.

  • For help or more information, contact information for the NC Board of Dental Examiners can be found by clicking HERE

Pediatric Children’s Dentistry Records Release Form

There are circumstances from time to time where the law will require us to use a signed dental records release form (for example, if you are moving here from out of state) in order to have access to a copy of your child’s dental history and records. In the event you need a copy of our release form, the link is to the right.

Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Click here to open and print the release form:

Peds Records Release Form
Patient Privacy Disclosure Policy

Pediatric Dental Insurance & Payment Policies

By design our pediatric dentists are not in network with any insurance companies and parents make all payments directly to us for our pediatric dental services. Payment for services rendered are due at the time of the appointment. This means we do not accept assignment and we do not take payment from any insurance company. Our administrative team will then electronically file your dental insurance claim on your behalf at no extra charge and the dental insurance company will directly reimburse parents. Anytime that payment in full is a true family hardship, we will gladly set up a monthly payment plan and work with you. We recognize that the best way to maintain full control over the quality of pediatric dental services is for our doctors to remain independent from what insurance companies dictate. Insurance companies do not always have your children’s best interest at heart. Our pediatric dental team is what is referred to as a “fee for service” practice. Parents will generally find that the difference between our fees and what your insurance company pays will not be significant. There is a pervasive myth pushed by insurance companies to the contrary. They do this not because they have the best interest of your children in mind, but rather because they wish to further expand their corporate power and profit. Believe it our not, sometimes what the insurance company would allow us to charge for a procedure might actually be higher than what we charge. In that case, we would never take advantage of that and charge you more. When your insurance company will not reimburse you our entire fee, you will find that the difference you are responsible for, in the long run is not significant. A trend in dentistry is for families to move from one dental home to another based on dental insurance coverage changes that occur with the company / employer parents work for. We believe that this is one of the worst consequences to have come out of the expansion of dental insurance. Families moving from place to place destroys the continuity of care, relationship building, and the ability for a doctor to truly know your children as they grow and develop. Remaining independent allows every family to stay in our practice and we firmly believe that it is important for children to have a consistent dental home while they are growing up. This is a strong predictor of whether or not they will adopt good oral health routines and seek routine dental checkup in adulthood.

Dental X-rays for kids are one of the best ways to detect tooth decay and problems in teeth that are not apparent to the doctor during a visual exam of the teeth.

Insurance Myths

Myth # 1

My insurance will pay 100% of all procedures if my dentist is in network with my insurance. When asked, most people believe that dental insurance pays 85%-100% of all your dental fees.


The reality is in general is very different and on average ranges from 50%-80%. Dental insurance rates are negotiated between your employer and the insurance company and there are literally thousands of network plans available. Our goal is to focus on being experts in taking care of you and your children. The more time we spend on insurance, the less time we have for your child.

Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Myth #2

Insurance companies work with dental offices to determine what benefits your child should truly have and what the actual true cost is for the pediatric dentist to provide the treatment necessary to care for patients. This is not the case at all.


What actually happens is that insurance companies set their own fee “schedules,” and each insurer uses a different set of fees that they will allow for various types of dental treatment. Those fees are referred to as “allowable” fees. The amount of money the insurance company has decided should be charged for a procedure is known as the UCR fee (usual, customary, or reasonable), and it varies widely across thousands of plans and companies.


When an insurance company reimburses you less than the dentist’s actual fee, and the explanation provided is that the fee charged is higher than the UCR, this implies that the dentist has charged an unusually high fee that is not customary and is unreasonable. Giving the impression that your dentist is overcharging when the insurance company has built in a 20-30% profit margin for themselves is not only inaccurate, it is misleading and unethical.

Refer A Patient Or Friend
To Our Pediatric Dental Team

Many of our patients are referred to us directly by a family dentist, and many of our existing patient families refer their friends and neighbors. We appreciate the trust and confidence you have shown in us! Whether you are a doctor or you are referring a friend or neighbor, you may use the interactive form below.

Peds Refer a Patent or Friend
Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Patients with active access to online scheduling may use the link below:

Online Scheduling For Pediatric Children’s Dental Appointments

Exciting News!  Some of our pediatric children’s dentistry appointments can be scheduled online directly by parents.

Please Note:

  • Not all appointment types can be booked online.

  • We require your child to have been previously seen by us prior to being granted online self-scheduling access.

  • In order to first be granted access, we must activate online scheduling for each individual patient and send you a login link via email.

Peds Schedue an Appointment
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