Your First Visit

***Parent/Guardian needs to be with the child at the new patient appointment

We require the completion of standard paper work for our new patients, including a medical history, general patient information, and HIPAA notice of privacy practices, upon the first visit. Click on the links below to download your new patient forms from Southern Illinois Pediatric Dentistry. If you would like to complete them in advance, you can complete the forms either by hand or online, and then print to sign and turn them in it at your first visit.

Click here to view and download all of the new patient forms for Columbia

Click here to view and download all of the new patient forms for Edwardsville


What to Expect

We want both you and especially your child to have a wonderful experience at the dentist. The first visit is an important one. This is our opportunity to ensure that your child is comfortable and looks forward to all future dental visits.

We will get to know you and your child, discuss his or her medical history and any past dental experiences, and address any concerns that you or your child may have.

Your child is welcome to play with the toys, color, or read a book in the waiting room while you enjoy complimentary bottled water or coffee and watch television or read a magazine!


What to Bring

Please bring a valid photo I.D. of parent or guardian (and guardianship papers if not biological parent) and your insurance card.


Insurance and Finance Options

We accept most major dental insurance.

If you do not have dental insurance, we’re always happy to work with you to help make your child’s dental care affordable.



***Each field requires a response before submitting this form. Please use N/A when appropriate.

New Patient Form





Select Which Office You Will Be Visiting

Has the patient or any siblings seen Dr. Snyder previously at Riverbend?

Was Your Child Referred To Us?

X-Rays Taken?

Is the Patient in Pain?


Any Swelling?

Do You Have Secondary Insurance?

14 + 2 =