New Patient for Kids

Please complete this form. If you have questions, give us a call and we are happy to help!

Kid Information

First Name *

Middle Initial *

Last Name *

Nickname

Gender *

Male

Female

Birthday *

Month

Day

Year

MEDICAID/Ins ID#

SSN (LAST 4 DIGITS) xxx-xx-

Street Address *

City *

State *

Zip *

Please list any medical conditions your child has: *

Please list any medications your child takes: *

Please list any medicines your child is allergic to: *

Is your child pregnant or nursing?

Yes

Insurance Company

Pediatrician's Name

Insurance Info

Medicaid patients: skip this section unless you have 2 dental insurance plans.

Policy Holder Name *

Policy Holder Birthday *

Month

Day

Year

Employer *

Policy Holder SSN (LAST 4 DIGITS) * xxx-xx-

ID# *

Group# *

Insurance Phone# *

Adult Information

Do you have legal custody of this child?

Yes

Legal Guardian's Info

First Name

Last Name

Relation to Child

SSN (LAST 4 DIGITS) xxx-xx-

Cell Phone

Home Phone

Work Phone

Digital Signatures

Medical Info InitialsI certify that I have provided complete and truthful information, knowing that providing incorrect or false information can be dangerous to my child’s health. *

I authorize the release of all necessary information to third party payors and/or health practitioners and request my insurance company to send payment directly to this office. *

I have been offered a copy of the Notice of Privacy Practices and agree to its terms. *

As the adult accompanying the child, I accept responsibility to pay today what insurance is not expected to cover. *

Appointment InitialsI understand that missed or broken appointments may prevent me from being able to schedule again. *

Informed InitialsI have been fully informed and all of my questions have been answered. I give my informed consent to be bound by all terms of all policies associated with Jared Cox DDS PA. *

We will provide you with good faith estimates based upon the information your carried provides to us about your policy. Please be aware that insurance carriers never guarantee payment according to the percentages they advertise to you, and they adjust their payments according to the fine details contained within your individual contract. After we submit your claim, your insurance carrier will review it to determine how much it will pay for your dental services. If your carrier pays more than we estimated the overpayment will be used to reconcile any family account balances do. If there are no account balances due, we will issue you a refund after all pending insurance claims have been received.

I understand that any insurance overpayment will be used to reconcile my family balance before a refund is issued to me. *

Initial

TFD estimates are good for 60 days after they are given. Please be aware that your insurance policy has a limited amount that your carrier will pay each coverage year for all your dental services. If you were seen or will be seen by another dentist in the current coverage year or if your treatment will require a referral to a specialist’s office, your coverage may be exceeded, and your estimated patient portion quoted on your estimate may be incorrect. Please be aware that TFD cannot attain accurate information from your insurance carrier about dental services provided by a previous dentist or specialist. If your carrier denies or downgrades your claim because your annual coverage limit has been exceeded or for any reason, your account with us will be adjusted according to the insurance downgrade and you will be responsible to pay the balance due in full within 30 business days.

I understand that if my coverage is exceeded or if my claims are denied/downgraded that I will pay the balance in full. *

Initial

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You guys have the BEST guest service! Andy (hygienist) is the sweetest!

- Carrie Mona

Everyone was so helpful and made me feel so relaxed, I can actually say I enjoyed my dental visit.

-,Linda Hollis

Wow is all I can say! Every business should strive for this kind of excellence!!

-Lori Betts

I have been so pleased with the service I have received! I have no fear of the dentist anymore and my fillings have been just right.

- Christy Austin

I went to Dr. Cox for my daughter’s first dental appointment. It was the best decision I could have made. After being thoroughly impressed by the employees’ professionalism and customer service, I recommend Dr. Cox to everyone I encounter.

- Carrie Young

Everyone is so sweet and caring. Dr. Cox’s staff made me feel really at ease.

- Maxiene Teague

My mouth feels so much better this morning. Thank you so much for fitting me in and helping me. It is always a pleasure being around your staff. They’re great!”

- Brent Early

This is the best dental service I have ever had. You guys do a great job!

- Mary Holloway

Dr. Cox did a wonderful job with my implant! It feels like the strongest tooth I have! I feel like I could eat gravel with it! (LOL) Best dental choice I could have made. Would gladly do it again if the need arose!

- Bruce Yokely

I couldn’t even tell you where the crown is that you made. I can’t tell a difference in it and my natural teeth.

- Karl McLarty

Having dental implants is one of the greatest decisions I have ever made.

- Cheryl Sterling

Jared, just wanted to say thanks for the great service your team gave me yesterday. I’ve never had a more comfortable cleaning and been treated so well as a patient. You are doing a stand-up job when it comes to customer service.

- Chad Froud

I’ve never been to a dentist’s office that is this nice. I love it here!

- Jenna James

One of the best experiences I’ve ever had!

- Betty J. Everett

I always have a great time when I come here. I’ve never been so relaxed in the dental chair.

- Melissa Nelson

Dr. Cox’s office is a great dental office. His staff is professional and courteous, and it’s always a pleasure to visit. The staff is amazing!

- Danny Watkins

I was so nervous because of past experiences but Dr. Cox’s staff put me at ease. Dr. Cox was able to completely change my expectations of what dental work has to be. If only all dentists were as good as him…

- Kyle Bracken

I have been so pleased with the service I have received! I have no fear of the dentist anymore and my fillings have been just right.

- Christy Austin

I love coming to the dentist. I get cookies and a goody bag!

- DeeAnn Martin

I have never had so much dental work done in one appointment that was painless from beginning to end. There was no swelling, pain, or adjustments needed. It was a wonderful experience!

- Marcella Bailey

Jared Cox and his staff are extremely extraordinary. They present themselves as organized, professional, and the most friendly people out of any dental or medical office I have ever entered.

- SebrinaTippett

This is the best dentist that I’ve been to. The facility is very up-to-date and the staff is extremely knowledgeable and patient-oriented. On top of all that, you leave with a cookie!

- Tu Ngo

It’s just a pleasure to come to Dr. Cox’s office. He and his team are so nice; it’s like I leave the “real world” for an hour every time I come.

- Jamar Blackmon

Greetings Dr. Fulmer!! Thank you for your selection of Dr. Cox, whom Paul and I feel has deep concerns about your former patients. From the moment we walked into his office, we felt welcome. Thanks again for your recommendation!

- Paul and Joyce Edwards

There’s no doubt you operate a World Class Business which is demonstrated through the cleanliness, organization, and overall quality of your facility, in addition to the professionalism of your staff to provide the best service possible with a very personal touch.

- Jimmy Swain

Any time my family has come to Dr. Cox, we have always felt very well cared for. The nurses are very sweet, kind, and caring. I get very anxious when I come to the dentist, but everyone here makes me very comfortable. Thank you all!

- Jennifer Hale

I was a little apprehensive about finding a new dentist. However, the staff is amazing about giving smiles and genuinely kind. My hygienist is extremely informative, thorough, and has a bright personality. It was the most pleasant dental experience I have ever had in my life.

- Kayla Geske

Today I had an unexpected experience at the dental office. New technology is so great! Instead of being concerned about keeping my mouth open and my tongue out of the way, the Isolite mouthpiece did it for me and my crown was built in this office by a computer in about an hour!

- Deanna Speer

There is nobody like Dr. Cox and his team! My son said he will never go to anyone else.

- Brenda Gibson

From the receptionist and insurance secretary on the phone - to the way my daughter and I were greeted - to the information provided by the sweetest hygienist and wonderful doctor - it was an incredible experience and I am delighted we found Dr. Cox.

- Samantha Rogers

View More Testimonies
Submit A Review

You guys have the BEST guest service! Andy (hygienist) is the sweetest!

- Carrie Mona

Everyone was so helpful and made me feel so relaxed, I can actually say I enjoyed my dental visit.

-,Linda Hollis

Wow is all I can say! Every business should strive for this kind of excellence!!

-Lori Betts

I have been so pleased with the service I have received! I have no fear of the dentist anymore and my fillings have been just right.

- Christy Austin

I went to Dr. Cox for my daughter’s first dental appointment. It was the best decision I could have made. After being thoroughly impressed by the employees’ professionalism and customer service, I recommend Dr. Cox to everyone I encounter.

- Carrie Young

Everyone is so sweet and caring. Dr. Cox’s staff made me feel really at ease.

- Maxiene Teague

My mouth feels so much better this morning. Thank you so much for fitting me in and helping me. It is always a pleasure being around your staff. They’re great!”

- Brent Early

This is the best dental service I have ever had. You guys do a great job!

- Mary Holloway

Dr. Cox did a wonderful job with my implant! It feels like the strongest tooth I have! I feel like I could eat gravel with it! (LOL) Best dental choice I could have made. Would gladly do it again if the need arose!

- Bruce Yokely

I couldn’t even tell you where the crown is that you made. I can’t tell a difference in it and my natural teeth.

- Karl McLarty

Having dental implants is one of the greatest decisions I have ever made.

- Cheryl Sterling

Jared, just wanted to say thanks for the great service your team gave me yesterday. I’ve never had a more comfortable cleaning and been treated so well as a patient. You are doing a stand-up job when it comes to customer service.

- Chad Froud

I’ve never been to a dentist’s office that is this nice. I love it here!

- Jenna James

One of the best experiences I’ve ever had!

- Betty J. Everett

I always have a great time when I come here. I’ve never been so relaxed in the dental chair.

- Melissa Nelson

Dr. Cox’s office is a great dental office. His staff is professional and courteous, and it’s always a pleasure to visit. The staff is amazing!

- Danny Watkins

I was so nervous because of past experiences but Dr. Cox’s staff put me at ease. Dr. Cox was able to completely change my expectations of what dental work has to be. If only all dentists were as good as him…

- Kyle Bracken

I have been so pleased with the service I have received! I have no fear of the dentist anymore and my fillings have been just right.

- Christy Austin

I love coming to the dentist. I get cookies and a goody bag!

- DeeAnn Martin

I have never had so much dental work done in one appointment that was painless from beginning to end. There was no swelling, pain, or adjustments needed. It was a wonderful experience!

- Marcella Bailey

Jared Cox and his staff are extremely extraordinary. They present themselves as organized, professional, and the most friendly people out of any dental or medical office I have ever entered.

- SebrinaTippett

This is the best dentist that I’ve been to. The facility is very up-to-date and the staff is extremely knowledgeable and patient-oriented. On top of all that, you leave with a cookie!

- Tu Ngo

It’s just a pleasure to come to Dr. Cox’s office. He and his team are so nice; it’s like I leave the “real world” for an hour every time I come.

- Jamar Blackmon

Greetings Dr. Fulmer!! Thank you for your selection of Dr. Cox, whom Paul and I feel has deep concerns about your former patients. From the moment we walked into his office, we felt welcome. Thanks again for your recommendation!

- Paul and Joyce Edwards

There’s no doubt you operate a World Class Business which is demonstrated through the cleanliness, organization, and overall quality of your facility, in addition to the professionalism of your staff to provide the best service possible with a very personal touch.

- Jimmy Swain

Any time my family has come to Dr. Cox, we have always felt very well cared for. The nurses are very sweet, kind, and caring. I get very anxious when I come to the dentist, but everyone here makes me very comfortable. Thank you all!

- Jennifer Hale

I was a little apprehensive about finding a new dentist. However, the staff is amazing about giving smiles and genuinely kind. My hygienist is extremely informative, thorough, and has a bright personality. It was the most pleasant dental experience I have ever had in my life.

- Kayla Geske

Today I had an unexpected experience at the dental office. New technology is so great! Instead of being concerned about keeping my mouth open and my tongue out of the way, the Isolite mouthpiece did it for me and my crown was built in this office by a computer in about an hour!

- Deanna Speer

There is nobody like Dr. Cox and his team! My son said he will never go to anyone else.

- Brenda Gibson

From the receptionist and insurance secretary on the phone - to the way my daughter and I were greeted - to the information provided by the sweetest hygienist and wonderful doctor - it was an incredible experience and I am delighted we found Dr. Cox.

- Samantha Rogers

View More Testimonies
Submit A Review

What to Expect

Massaging Dental Chairs
TVs above Your Dental Chair
Noise Reduction Headphones
Freshly Baked Cookies
Family Movie Room
Scented Candles
Neck Support Pillows
Warm Blankets
Soft Music
Relaxation Books
Friendly Faces
Latest Technology

Inside Main Street Medical Center . 400 S. Main Street, Suite 300, Searcy AR 72143 . 501-268-3223

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New Patient for Kids

What to Expect