PATIENT REGISTRATION

B.  (If you have brought your Dental Card with you, you can omit section B!)

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

C.  (If Patient is responsible for account, write patient by NAME and the rest of section C can be omitted).

PERSON FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT 

D.

EMERGENCY CONTACT

CLOSEST RELATIVE NOT LIVING WITH YOU

FOR OFFICE USE ONLY DISCLAIMER:

Parents are required to remain in this dental office during their child’s dental visits.  This affords parents the opportunity to ask questions and our staff the opportunity to explain and discuss our findings. Also, circumstances may arise that require a change in dental treatment, resulting in fee differences.  If parental consent cannot be obtained, we reserve the right to continue with treatment deemed necessary or to discontinue treatment and reschedule the appointment.  In certain instances, written permission from the custodial parent will be sufficient to allow another party to bring this child to a scheduled dental appointment.

dental appointments. 

Consent for Treatment

1.  I hereby authorize doctor or designated staff to perform a thorough examination, take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) 

’s dental needs.

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medications as necessary.  I fully understand that using anesthetic agents embodies certain risks.  I understand that I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependent’s, and it is understood that the dentist will not bill a third party for payment on me or my child’s behalf other than my insurance company.  I understand that estimated coinsurance payment is due at the time service is rendered unless written arrangements have been made with this office prior to treatment.  I understand and agree that insurance estimates are made with the best available information and in the event services are changed or denied by the insurance company, the bill will be my sole responsibility.  In the event that payments are not received by agreed upon dates, I understand that finance charges will apply and will be added to my account.  If required, I also understand that a check of my credit history may be made.  I understand and agree that if my account is turned over for collections, a fee of 33.3% will be added to my total balance.