NOTE: We CANNOT guarantee that your insurance will cover Fluoride at this visit. You will be responsible for payment if it is not covered
I hereby authorize any of the Dr's at Best Dentist 4 Kids PC, to perform upon First Name* Last Name* any of the following treatment(s), as discussed by the Doctor:Exam, Prophy, Fluoride, X-Rays, Silver or White Fillings, Silver Crowns, White Crowns, Nerve Treatments (Direct or Indirect Pulpotomies, Pulpotomies, Pulpectomies), Extractions, SpacersDr. Checchio, Dr. Koumaras, or an associate will perform 1 or more of above dental procedures and any additional procedures that are considered necessary during treatment on my child.The Doctor has explained the treatment/procedure(s) including the purpose of the procedure, and possible alternatives. He/She has also advised me of the possibility of complications, the expected consequences of the treatment/procedures, and the possible results of non-treatment.No one has guaranteed any specific result of the treatment/procedure(s).I understand that the doctors may discover medical conditions that they did not know about that require a change in the procedure, a more extensive procedure, or a different procedure. Knowing this, I authorize the doctor to perform the procedure(s) that in their best judgement are necessary or wise for the well-being of the child.My Signature on this form shows that (1) I have read and understand the information on this form, (2) the treatment/procedure(s) described and discussed above have been satisfactorily explained to me, and that there is no guarantee the dental procedure will be successful and infection, extraction, or root canal may be needed after this treatment is completed, (3) I have had a chance to ask questions and can do so the day of the procedure, including alternative treatments as well as advantages and disadvantages of each, including no treatment (4) I have been given all of the information I desire concerning the treatment/procedure(s), (5) I consent to the performance of the treatment/procedure(s).
Thank you for choosing us as your dental care provider. We believe that every patient deserves the very best in dental care. We also believe that everyone benefits when specific financial agreements are agree upon in advance. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment.
We request that any co-payments, deductibles, and any services not covered by your insurance company to be paid on the date of service. The balance is your responsibility whether or not your insurance company pays us. We cannot bill your insurance unless you provide us with the information at your initial visit. In addition, please update us on any and all changes to your insurance, including type, group number, indentification number, etc. Most importantly, you must notify us if your employer changes.
Please be aware that your dental insurance policy is in an agreement between you and your insurance company. If your insurance has not paid us within 90 days, the entire balance will automatically be transferred to your account. Note that some, and possibly all of the services provided may be non-covered under the terms of your policy. YOU ARE ULTIMATELY RESPONSIBLE FOR ANY AND ALL CHARGES NOT PAID BY YOUR INSURANCE COMPANY FOR ANY REASON.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients, and our fees fall within "reasonable and customary" for our area. The treatment plan made by our doctors is based upon the dental necessity of your child, NOT the type or amount of dental coverage you have.
Any outstanding account for which we have no received payment in 90 days will be assessed a $25.00 collection fee, and be forwarded to a collection agency. In addition all returned checks will be subject to the returned check fee.
Thank you for reviewing our financial policy. We look forward to providing the highest quality dental care.