New Patient Forms
This two-page packet includes Patient Registration and Patient Dental/Medical History information.
Please note: A legal guardian is required to be present at the child’s first appointment.
Pediatric Dental Specialists of Indiana, P.C.
Patient Resources
Helpful information and printable forms for families preparing for a visit to our Kokomo office.
Printable Patient Forms
For your convenience, the forms below may be printed at home and completed by hand before your appointment. These forms are provided as printable PDFs and are not submitted through our website.
HIPAA / Protected Health Information Form
Use this form to provide instructions regarding disclosure of protected health information and permitted contacts.
Printing the forms: Open the form using the button above, choose Print in your PDF viewer or browser, complete the printed form by hand, and bring it with you to the appointment.
Preparing for Your Child's Visit
Routine first dental visits at our office generally begin around 12 months of age. If you have a concern about your child's teeth or oral health, please contact our office—we can see children earlier when needed.
Before Your VisitPrint and complete any patient forms you need before arriving.
Questions?Call our office at 765-453-2267 if you have questions about your child's appointment.
Office HoursMonday through Thursday, 8:00 AM–5:00 PM.
New Patients & Insurance
We are accepting new patients. In-network with Anthem, Delta Dental, Cigna and Medicaid. Contact your insurance if you have any questions about your child’s coverage.
Our Kokomo Office
Office2705 S Berkley, Suite 2B
Kokomo, IN 46902
Kokomo, IN 46902
ContactPhone: 765-453-2267
Fax: 765-453-1150
Fax: 765-453-1150
HoursMonday–Thursday
8:00 AM–5:00 PM
8:00 AM–5:00 PM