Patient Forms

Please print and fill out these forms so we can expedite your first visit:

In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.

Your first visit to Dr. Ellen Im Pediatric Dentistry establishes a vital foundation for our relationship with you. During the first visit, we make sure to obtain important background information, like your medical history, and give you time to get to know your doctor. To understand what to expect for your first visit to our practice, please read through this page. You'll find all the practical information you need, such as a map and directions to our office, practice hours, payment policies and more. There's also background information about our committed staff and our first visit procedures. You can even save some time at your first visit by printing out and completing the patient forms in advance of your appointment.

Mission Statement

Our practice is working together to realize a shared vision of uncompromising excellence in dentistry.

To fulfill this mission, we are committed to:

  • Listening to those we are privileged to serve.
  • Earn the trust and respect of patients, profession and community.
  • Exceed your expectations.
  • Ensure a creative, challenging and compassionate professional environment.
  • Strive for continuous improvement at all levels.


We appreciate and expect payment for the dental services to our patients at the time of the visit, regardless of the dental benefit coverage. We accept cash, personal checks, Visa, MasterCard, American Express, Discover, as well as offer Care Credit financing (a dental credit card). Our administrative staff will be happy to provide information and answer questions about fees, financial arrangements and insurance coverage.

We are Premier Providers for MOST PPO INSURANCES

At Poway Kids Dental Care, we are proud premier providers for MOST PPO Insurances to ensure that our patients receive affordable, quality service. If you have a dental benefit plan, please bring your insurance information with you. Our team will be happy to review your dental benefit coverage with you. They will work with you upon request to determine the extent of your coverage and to help you receive the maximum allowable benefits. Some procedures your child needs may not be covered by your plan or a deductible or a co-payment may be required. We will be pleased to assist in filing a pre-treatment estimate with your dental insurance company. Your level of insurance coverage is determined by the policy your employer selects. If you think your coverage is insufficient, you may wish to address this with your employer.

Here is a list of some of insurances that we participate with:

  • Aetna
  • Alliance
  • Assurant
  • Anthem
  • Blue Cross/Blue Shield
  • CareFirst
  • Cigna
  • Delta
  • DenteMax
  • DentaQuest
  • GEHA
  • Guardian
  • MetLife
  • UnitedConcordia
  • All FSAs  & more!

We are proud to offer financing options including CareCredit which offers a dental credit card with little to no interest and also, an in-house dental insurance plan. Please ask our friendly staff for more details.

What To Expect

Being well-prepared for your appointment will ensure that the doctor has all of the needed information to provide the best possible care for you. It also will help relieve any unnecessary anxiety you may be feeling. Educate yourself on your symptoms by reviewing the content on this Web site. Also, take some time to review our staff page and familiarize yourself with the doctors. We look forward to your first visit.

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