Downloadable Forms & Online Submission Forms

You can feel free to submit an online form or print any of our forms out to fill in and bring with you on your next visit to our office.

Online Patient Forms

You may access the following forms to assist us with your care. Please complete the following forms, and click the “Submit” button at the bottom of each form.

Printable Patient Forms

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


These forms require Adobe Acrobat Reader.

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The first step toward achieving a beautiful and healthy smile.

PATIENT ALERT

Out of concern for patient and staff safety, we closed our offices on March 19th to help mitigate the spread of the Covid-19 virus, and were planning to reopen on April 4th.

Late yesterday, Virginia Governor Ralph Northam issued an Executive Order prohibiting all elective, non-emergency medical and dental procedures until April 24, 2020. The order is considered MANDATORY and carries the effect of law. Any violation of the order can be considered a criminal offense. You can read about the Governor’s order at (https://www.vadental.org/news-details/2020/03/26/order-of-public-health-emergency-no.-2) and at (https://www.governor.virginia.gov/media/governorvirginiagov/executive-actions/Order-of-Public-Health-Emergency-Two—Order-of-The-Governor-and-State-Health-Commissioner.pdf) We are now planning / hoping to reopen our offices on April 25th, and will operate under CDC and VDH guidelines pertaining to the delivery of dental services, and the operation of public spaces in effect then.

If you believe that you have a severe and life threatening Dental Emergency please call our after-hours help line at 571-575-5790, and one of our team members will assist you in determining a proper course of action.

If you are having trouble reaching our after-hours help line, below are a few online services where doctors can write a prescription for pain medication and antibiotics.

We are truly sorry for the inconvenience this is creating for all of us, and look forward to seeing each of you soon.

– The Doctors and Team Members of Golden Pediatric Dentistry & Orthodontics


What can I do if I have a Dental Emergency?

You can call our after-hours help line at 571-575-5790, and one of our team members will assist you in determining a proper course of action.

If you are having trouble reaching our after-hours help line, below are a few online services where doctors can write a prescription for pain medication and antibiotics.

Online Urgent Care Resources: