We strive to make each of your child’s visits pleasant and comfortable.
Our goal is to teach your child oral habits, which will help, keep their smile beautiful for their lifetime.
Your child’s overall health as well as any medications, which your child takes, could have an important inter-relationship with the dental care your child receives. Please answer each of the following questions completely.
Has your child ever had any of the following?
Does your child:
I authorize the Dentist or designated staff treating my child to perform such diagnostic aids deemed appropriate to make a thorough diagnosis of my child needs. Upon such diagnosis, I authorized the Dentist to perform all recommended treatment and therapeutic procedures to include administering medications as prescribed by the Dentist and mutually agreed upon by me. I assign all dental insurance benefits to which my child is entitled to the extent permitted under my dental insurance policy(s) to the Dentist. This form also authorized this Practice to submit insurance claim forms and receive payment directly from the insurance carrier with the notation “SIGNATURE ON FILE”. I authorized the Dentist to release treatment records/x-rays or any other information deemed pertinent to the insurance carrier as necessary and/or requested.
I agree to be responsible for payment of all services rendered on my dependent. I agree that any unpaid claims the carrier does not pay or any balance that extends beyond 45 days from the date of treatment might be assessed to a service charge and/or turned over to a collection agency. I am aware that if the account is turned over to a collection agency, I will be responsible to pay 25% collection agency fees and/or $50.00 court costs and attorney fees.
I have read the above conditions of treatment and payment and agree to their content.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The interested parties may revoke this authorization in writing only. n in writing only. Please note once records are established there is a $35.00 charge for duplication of records including $35.00 charge for duplication of records including x .00 charge for duplication of records including x-rays. A $45.00 Broken appointment fee will be applied for missed or canceled appointments without 48 hours notice.
Your information will be encrypted.