Patient Forms

You may access the following forms to assist us with your care. Please print and fill out the following forms, then bring them to your appointment.

Common Problems

Tooth Decay

h-pediatric3.jpgTooth decay, also known as caries or cavities, is preventable. Carbohydrate-rich foods, such as candy, cookies, soft drinks and even fruit juices, leave deposits on your teeth. Those deposits bond with the bacteria that normally survive in your mouth and form plaque. The combination of deposits and plaque forms acids that can damage the mineral structure of teeth and eat away at tooth enamel, resulting in tooth decay.

Sensitive Teeth

Your teeth expand and contract in reaction to changes in temperature. Hot and cold foods and beverages can cause pain or irritation to people with sensitive teeth. Over time, tooth enamel can be worn down, gums may recede or teeth may develop microscopic cracks, exposing the interior of the tooth and irritating nerve endings. Simply breathing cold air can be painful for those with extremely sensitive teeth.

Gum Disease

Gum, or periodontal, disease can cause inflammation, tooth loss and bone damage, and common indicators are consistent bad breath or a bad taste in the mouth. Gums in the early stage of disease, known as gingivitis, can bleed easily and become red and swollen. As the disease progresses to periodontitis, teeth may fall out or need to be removed by a dentist. Gum disease is highly preventable and can usually be avoided through daily brushing and flossing.

Bad Breath (Halitosis)

Daily brushing and flossing helps to prevent the build-up of food particles, plaque and bacteria in your mouth. Food particles left in the mouth deteriorate and cause bad breath. While certain foods, such as garlic or anchovies, may create temporary bad breath, consistent bad breath may be a sign of gum disease or another dental problem.

Canker Sores

Canker sores (aphthous ulcers) are small sores inside the mouth that often recur. They have a white or gray base surrounded by a red border. Generally lasting one or two weeks, the duration of canker sores can be reduced by the use of antimicrobial mouthwashes or topical agents.

Orthodontic Problems

A bite that does not meet properly (a malocclusion) can be inherited, or some types of improper bites may be acquired. Common causes of malocclusion include missing or extra teeth, crowded teeth, misaligned jaws, injuries/trauma or developmental issues, such as finger or thumb sucking.

Kids Korner

Bippo Lingo!

h-pediatric5.jpgTickle Stick – Disclosing solution on a cotton swab that helps us see where the patient needs to brush better.

Mr. Thirsty – A suction or vacuum that drinks up all of the toothpaste.

Magic String – Dental floss.

Tooth Muscles – Fluoride varnish.

Tooth Bugs, Cavity Bugs or Sugar Bugs – Tooth decay.

Tooth Mirror – Small mouth mirror.

Tooth Counter – Explorer that is used by the doctor to find cavities.

Pictures – X-rays of the teeth.

Happy Air – Nitrous Oxide or laughing gas. The happy air comes from our "Bippo the Hippo Nose" and helps your child relax while his or her tooth is being put to sleep.

Sleepy Juice – Our anesthesia used to numb your child's tooth. We never use words like “shot” or “needle.” We simply squirt sleepy juice all around the tooth and explain to your child that they may feel tiny little pinches around their tooth as it drifts off to sleep. If they are really quiet, they may hear the tooth snore!

Tooth Raincoat – A rubber dam that isolates the tooth we are working on, keeping it dry and keeping all the cavity bugs from falling into the child's mouth while Mr. Whistle blows them away.

Tooth Ring – A small clamp that hugs your child's tooth and holds their tooth raincoat on.

Mr. Wiggle – Our high-speed dental handpiece that whistles really loudly and blows all of the cavity bugs out of the child's tooth.

Mr. Bumpy – Our slow-speed dental handpiece that bumps all around the tooth and tickles the cavity bugs away.

Coloring Pages!

Tooth Decay Prevention

Regular Dental Visits

h-pediatric4.jpgIn order to maintain a healthy smile, it is vital to have professional cleanings and regular check-ups. Therefore, you should visit your general dentist twice a year (once every six months). At each appointment, your dentist will examine your teeth and provide an evaluation of existing dental problems and proposed treatment.

Tooth Decay Prevention

Tooth decay is a progressive disease resulting from the interaction of bacteria that naturally occur in your mouth and the sugars consumed in your diet. Sugar causes a reaction in the bacteria, which causes the bacteria to produce acids. These acids break down the minerals in teeth, forming a cavity. Dentists can remove the decay and fill the tooth using a variety of fillings or cover the tooth with a crown. Avoiding unnecessary decay simply requires strict adherence to a dental hygiene regimen: brushing and flossing twice a day, regular dental check-ups, diet control and fluoride treatment.

Diet Control

The teeth, bones and soft tissues of the mouth require a healthy, well-balanced diet. A variety of foods from the five food groups help minimize and avoid cavities and other dental problems. Consuming sugary and starchy foods should be limited, including candies, cookies, chips and crackers. Healthier foods, such as vegetables, low-fat yogurt and cheeses, help promote stronger teeth.


The grooves that form the chewing surfaces of the back teeth (molars) are extremely difficult to clean of bacteria and food. As the bacteria react with the food, acids form and break down the tooth enamel, causing cavities. Tooth sealants can protect these areas by sealing the grooves, preventing bacteria and food particles from accumulating. The sealants are made of a resin material that is applied to the back teeth, molars, premolars and any area prone to cavities. Sealants last for several years but needs to be checked during regular appointments.


Fluoride is a substance that helps teeth become stronger and resistant to decay. Regularly drinking fluoridated water and daily brushing and flossing ensures significantly fewer cavities. Many, if not most, public water sources contain fluoridated water. Your dentist can evaluate the level of fluoride in your primary drinking water source and recommend fluoride supplements if necessary. There are also many kinds of toothpastes, mouthwashes and even some dental flosses that contain fluoride.


Q. Why should my child see a pediatric dentist instead of our regular family dentist?

h-pediatric2.jpgA. Pediatric dentistry is a dental specialty that focuses on the oral health of young people. Following dental school, a pediatric dentist has two to three years additional specialty training in the unique needs of infants, children and adolescents, including those with special health needs.

Q. At what age should my child have his/her first dental visit?

A. "First visit by 1st birthday" is the general rule. To prevent dental problems, your child should see a pediatric dentist when the first tooth appears – usually between 6 and 12 months of age – and certainly no later than his/her 1st birthday.

Q. How should I clean my baby's teeth?

A. A toothbrush with soft bristles and a small head, especially one designed for infants, is the best choice for babies. Brushing at least once a day, at bedtime, will remove plaque bacteria that can lead to decay.

Q. What is baby bottle tooth decay, and how can I prevent it?

A. Baby bottle tooth decay is a pattern of rapid decay associated with prolonged nursing. It happens when a child goes to sleep while breast-feeding and/or bottle-feeding. During sleep, the flow of saliva is reduced, and the natural self-cleansing action of the mouth is diminished. Avoid nursing children to sleep or putting anything other than water in their bedtime bottle.

Q. How can I help my child through the teething stage?

A. When teeth erupt, sore gums are part of the normal eruption process. The discomfort is eased for some children by use of a teething biscuit, a piece of toast or a frozen teething ring. Your pharmacy should also have medications that can be rubbed on the gums to alleviate the discomfort.

Q. Can thumb sucking be harmful for my child's teeth?

A. Thumb and pacifier sucking habits that go on for a long period of time can create crowded, crooked teeth or bite problems. If children are still sucking their thumbs or fingers when their permanent teeth erupt, a mouth appliance may be recommended by your pediatric dentist. Most children stop these habits on their own.

Q. When should my child start using toothpaste?

A. Do not use fluoridated toothpaste on children until age 3. Earlier than that, clean your child's teeth with water and a soft-bristled toothbrush. After age 3, parents should supervise brushing. Use no more than a pea-sized amount of toothpaste, and make sure children do not swallow excess toothpaste.

Q. If my child gets a toothache, what should I do?

A. To comfort your child, rinse his/her mouth with warm salt water, and apply a cold compress or ice wrapped in a cloth on your child's face if it is swollen. Do not put heat or aspirin on the sore area, but you may give the child acetaminophen for pain. Please see us as soon as possible.

Q. My child plays sports. How should I protect my child's teeth?

A. A mouth guard should be a top priority on your child's list of sports equipment. Athletic mouth protectors, or mouth guards, are made of soft plastic and fit comfortably to the shape of the upper teeth. They protect a child's teeth, lips, cheeks and gums from sports-related injuries. Any mouth guard works better than no mouth guard, but a custom-fitted mouth guard fitted by our dentist is your child's best protection against sports-related injuries.

Q. If my child gets a cavity in a baby tooth, should it still be filled?

A. Primary, or "baby," teeth are important for many reasons. Not only do they help children speak clearly and chew naturally, they also aid in forming a path that permanent teeth can follow when they are ready to erupt. Some of them are necessary until a child is 12 years old or older. Pain, infection of the gums and jaws, impairment of general health and premature loss of teeth are just a few of the problems that can happen when baby teeth are neglected. Also, because tooth decay is really an infection and will spread, decay on baby teeth can cause decay on permanent teeth. Proper care of baby teeth is instrumental in enhancing the health of your child.

Q. What should I do if my child knocks out a permanent tooth?

A. First of all, remain calm. If possible, find the tooth and hold it by the crown (top) rather than the root. Replace the tooth in the socket, and hold it there with clean gauze or a washcloth. If you can't put the tooth back in the socket, place the tooth in a clean container with milk or water, and take your child and the glass immediately to the pediatric dentist. Time is essential, so the faster you act, the better your chances of saving the tooth.