For your convenience, we have provided our patient forms online. We invite you to fill them out before your child’s appointment with Drs. Richard Ruffalo, Molly Lanz, Priyanka Vaddi, or Courtney Uselton. This will save you time in our office and make your experience much smoother. If you have questions about our patient forms or about pediatric dentistry in Pittsburgh, Imperial, and McMurray, Pennsylvania, please contact Pediatric Dentistry South today. We will be happy to help you.

New Patient Policy

To provide a safer environment for our patients, and to ensure that the care we provide is in line with the Pediatric Medical Society, the AAP and the CCDC, Pediatric Dentistry South, Inc. (the “Practice”) is implementing the following policies and procedures regarding vaccinations. Effective September 1, 2018, we will no longer accept patients who have not received all vaccinations recommended by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the

American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. The only exception to this policy will be for patients who provide a valid and documented medical reason for not receiving the recommended vaccinations.

For those current patients who have not been vaccinated, please be advised that we will not be able to provide additional treatment (except for emergency care) beyond your next scheduled appointment unless the patient has received all recommended vaccinations.  Because Pediatric Dentistry South is unable to provide dental care for children who have not been vaccinated, you may wish to contact the Dental Society of Western Pennsylvania at 412-321-5810 for help in locating a new provider.

New Patient Policy. Click here to learn more!

Please open and complete the following forms as instructed by the office. After filling out the entire form, hit the SUBMIT button to have the form sent to our office electronically.

  1. New Patient Welcome
  2. HIPAA Agreement Form
  3. Medical History and Consent Form
  4. Financial Responsibility Form
  5. Privacy Notice
  6. Patient Information Form
  7. Medical History Update (Existing Patients Only)