Finger Sucking Yes No* How long? blanks* Still active? Please SelectYESNO*
Pacifier Yes No* How long? blanks* Still active? Please SelectYESNO*
Thumb Sucking Yes No* How long? blanks* Still active? Please SelectYESNO*
I give my consent to needed dental services, local anesthetic, oral medications and acceptable methods for rendering dental care forblanks* (child's name).
Please list the name and relationship of authorized persons. Use the + symbol to add additional names. Enter NONE of there are no other Authorized Persons.
I give my consent to the above listed authorized persons to accompany my child to the office of Pediatric Dental Partners for dental appointments and to make any necessary decisions regarding dental treatment for my child (patient name listed above), including but not limited to:
I understand that this consent will be valid unless I rescind in writing.
Pediatric Dental Partners is dedicated to helping your child reach and maintain excellent dental health. Our goal is that you and your child share the same values as our practice for optimal dental health.
It is important that your child shows up for their scheduled dental appointment. Missing a dental appointment keeps your child from receiving the proper dental treatment recommended by the Doctors and it prevents the Doctors from scheduling other patients who need treatment.
For those reasons, our policy is to dismiss a patient after missing two consecutive appointments without timely notification. We require 48 hours’ notice if you need to reschedule your child’s appointment. We appreciate you allowing our practice to be your child’s dental provider and for understanding the need for our practice to enforce this policy.
Thank you for choosing Pediatric Dental Partners as your child’s dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read, and sign prior to any treatment.
PAYMENT IS DUE AT THE TIME OF SERVICE WE ACCEPT CASH, CHECKS, OR VISA/MASTER CARD/ DISCOVER AND CARE CREDIT
REGARDING INSURANCE We require your portion of services to be paid at the time of service. The balance is your responsibility whether your insurance company pays or not. We cannon file with your insurance company unless you give us your insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to the contract. In the event that your insurance coverage changes, please bring your new insurance card to the first visit following the change. If your insurance company has not paid your account in full within 45 days the balance will be due by you.
Since we are not a preferred provider with any insurance company, we do not accept co-pays for HPO, HMO, or PPO.
TIME OF SERVICE The parent, adult or guardian accompanying the child is responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit play (Visa, MasterCard, Discover) or payment by cash or check at the time of service has been verified.
CANCELLATION AND NO-SHOW POLICY We require 48 hours notice for any appointment changes.
INTEREST We reserve the right to charge interest and collect any fees incurred by us to your account when it is not paid in full.
I understand and consent to the above information.
Thank you for choosing Pediatric Dental Partners for your child’s dental care. Our mission is to give your child the best possible treatment available. In order to accomplish this, we have set some guidelines to assist us. We as k that you read over our suggestions with your spouse and any other adult that ay bin your child to our office. For your comfort ONE OR BOTH PARENTS are welcome to accompany your child to the treatment area. Once your child is in the treatment area it is OUR TIME to provide care. Too many people around your child may take attention away from the Doctor who is trying to treat your child with expedience and care. If you have too many questions or concerns, feel free to call us. Remember, these suggestions have been set tot make your child’s visit as well as yours a very pleasant and positive one.
Please remember these suggestions. They have been put in place to aid in the care for and of your child. Because it is your child we will do as you wish, but we reserve the right to stop and explore other options if necessary. We hope these guidelines will reinforce the fact that our mission is to PROVIDE THE ABSOLUTE BEST CARE TO OUR PATIENTS. Again, we thank you for choosing our office for your child’s dental care.