www.transcendentist.com - Pediatric Registration Form

Financial Policy
Dr. Ruhi Sangha / Dr. Praj Kamat

3030 Ashby Ave, Suite 101, Berkeley, CA 94705

NEW PATIENTS: (510) 800-7660 / EXISTING PATIENTS: (510) 841-3040 / FAX NUMBER: (510) 841-3044
We are committed to providing your child with the best possible dental care. We will be happy to answer any questions regarding our policy or fees at any time.
- All patients must complete our "PATIENT REGISTRATION FORM" before being seen by the doctor.
- FULL PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED.
- WE ACCEPT CASH, CHECKS, AND VISA / MASTERCARD.
- THERE WILL BE A $25.00 CHARGE FOR CHECKS RETURNED TO OUR OFFICE.
MINORS ACCOMPANIED BY AN ADULT: The adult accompanying a minor, his/her parents (or guardians), are responsible for FULL PAYMENT at the time services are rendered.

UNACCOMPANIED MINORS: The patient is to bring payment with them at the time services are provided. Non-emergency treatment will be DENIED unless charges have been pre-authorized to an approved Visa/Mastercard credit card or paid by cash or check at the time services are rendered.

SEPARATED OR DIVORCED PARENTS: The parent accompanying the child is responsible for payment unless prior arrangements are made.

REGARDING INSURANCE: For all insured patients, payments are expected at the time services are rendered. We can assist you by filing the claim electronically with your insurance carrier or will provide you the necessary information for you to submit to your insurance carrier. Reimbursement from your insurance company will be made directly to you. YOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF YOUR ACCOUNT. Failure to pay the outstanding balance within the first billing cycle will result in a $5.00 service charge.

Insurance is a contract between you and your insurance company. We are NOT a party to this contract. We may contact your insurance company to obtain benefits. Benefits obtained are subject to change by your employer or group policy. We will not become involved in disputes between you and your insurance company.

MISSED APPOINTMENTS: Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $25.00 - $50.00. Please help us to serve you better by keeping scheduled appointments. However, if your child is ill on the day of their appointment, please call our office to reschedule.
Responsible Party (signature) *

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Responsible Party Name *

First Name Last Name
Date *

Month Day Year
Date

Acknowledgment of Receipt of Privacy Practices Notice and Dental Material Fact Sheet
This document acknowledges that you have received a copy of
1. Notice of Privacy Practices
2. Dental Material Fact Sheet.
This document is not a contract, authorization, release, or consent form. This document will remain in your records.
*

From time to time we apprise our clients of events that may be of interest to them via email or mail. Please check here if you do NOT wish to be notified of such events.
I {childsName} Acknowledge that I have received a copy of the Notice of Privacy Practices and the Dental Material Fact Sheet.
Signature *

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Patient's Name *

First Name Last Name
Date *

Month Day Year
Date
Parent/Guardian Print Name

First Name Last Name
Should be Empty:

Pediatric Registration Form

Separated Parents

PARENT NUMBER 1 (RESPONSIBLE PARTY)

PARENT NUMBER 2 (RESPONSIBLE PARTY)

EMERGENCY CONTACT INFORMATION

PRIMARY INSURANCE INFORMATION

HEALTH HISTORY

Does / Has Your Child

Does your child currently have, or has a history of

DENTAL HISTORY

Financial Policy

Acknowledgment of Receipt of Privacy Practices Notice and Dental Material Fact Sheet