Obtained Small Smiles Patient Information Forms

Dropped Into a Small Smiles Clinic in South Carolina today and picked up some forms to pre-fill out prior to an appointment.

See the Forms here

The main forms for the patient to fill out is manila card stock patient folder. The front part is the only part the patient or guardian fills out prior to treatment, the signs at the bottom. It's not until the folder is open that the Patient Behavior Management Procedures are listed. Long after the parent or guardian has signed and consented to treatment.

I find this a bit sneaky.

As stated this in the patient file, the parent or guardian does not take any of this info with them. You can see in the picture when the folder is open on the left hand side lists the procedures and the right side is used to document appointments, visits and work performed.

What I find very misleading is that there is only one place for the parent or guardian to sign and it's only of the front just after the patients medical history has taken. Usually if there are other sections of documents that you need to read there would be a place for initials or a signature after that all important section.

At the bottom of the front page, the only page the parent or guardian fills in it says:

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth have been answered to my satisfaction. I will not hold the dentist, or any other members of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. I have also read and understand the Pediatric Dentistry Patient Management Techniques on page 2 of this form and give my consent for their use.

The way this is laid out it appears that you only read and fill out the front page. When you open the file folder it appears the inside is for the dentist to record the treatments.

This is a blanket signature agreement. Sections are not laid out clearly for the parents or guardian to read, sign, and understand to the full extent as it should be.

It's very sneaky to have a place for a signature acknowledging something prior to getting to that section. I don't know that I've ever seen any kind of treatment agreement, contract or other official document that has a place to sign prior to getting there, have you?


There absolutely should be a place to sign at the bottom of the second page acknowledging the parent or guardian has read the Patient Management Techniques and a place for the dental assistant or dentist to sign under it acknowledging that "techniques" were clearly explained and demonstrated.