As specialists in pediatric dental care, we would first like to thank you for the opportunity to welcome your child into our dental family!! As experts in children's dentistry, we may do things differently than an adult dental office. As a partner in your child's dental needs, we want to provide you with some information to ease your anxieties concerning the first dental visit in our office!

HOW TO PREPARE YOUR CHILD FOR THE FIRST VISIT TO OUR OFFICE

-On an initial visit to our office, we "count" teeth, "brush" teeth, and get "pictures"/x-rays of teeth. If you have been referred from another office, please bring any x-rays done. This will prevent us from doing the same procedure twice!

-We DO NOT treat your child's cavities on this first visit! Even if your child has seen a dentist in the past, our treatment plans are based on each individual's needs, which change based on age and anxiety level. This fist visit allows us to meet your child, obtain a medical history, and establish a plan of action.

-We use age appropriate language to explain to your child what will occur during the visit. We DO NOT use languages such as "shot", "drill", or "pull teeth," and we ask you avoid these words as well. Often the safest answer to your child's inquires is "I don't know, but I will be with you for every step!" Our staff is experts at explaining procedures with age appropriate language.

-A legal guardian MUST BE PRESENT for the first visit. At this visit, you will have the opportunity to give permission for others to bring your child and make medical decisions for your child.
Our mission is to provide the best dental care available for your child, and we feel honored to be a partner in his/her dental health. We look forward to meeting your entire family!

Sincerely,

The Staff and Dentists of Elizabethtown Dentistry for Children
 

In order for the child that you have brought to this office to receive dental treatment, you need to digitally sign the following statement:

I am responsible for:

the child who is to see the doctors of Elizabethtown Dentistry For Children for dental treatment. I have full authority to authorize the dental treatment which this child is to receive. I agree that I will be personally responsible for the payment of the bill for these dental services, even if there is some other party who should share this responsibility or be separately responsible for the bill. (In other words, even if there is a Court Order or Divorce Decree stating that the other parent of the child is responsible for his or her dental expenses. I understand that it is my personal responsibility to the doctors of Elizabethtown Dentistry For Children to pay this bill, and I will then have to seek recovery of the amount paid from the other responsible party.)

I understand it is my responsibility to know what services have been previously rendered and what my insurance will or will not cover. It is my responsibility to inform the DMD what services have been done so they will not be repeated, possibly leaving me with an unwanted balance.

Further, this is a notification that we, the doctors of Elizabethtown Dentistry For Children, may have an interest in the facility in which your child received treatment.

We would like to take this opportunity to welcome you and your child to our dental practice. We appreciate the faith you have shown in entrusting your child to our care.
In order that you may understand our office policies regarding appointment, we are providing this statement of our policy. This policy was formulated in order to carry out our objective of providing the highest standard of care to your child in a timely manner. For this to occur, it is important that if any appointments are needed after today, that they be kept. It is extremely difficult to provide quality dental care when multiple appointments are made and then not kept. This is also true when additional appointments which are needed are not made. The following are our office policies having to do with the scheduling of appointments:

1. It is the responsibility of the parent or guardian to make and keep all appointments for the child.

2. We understand that there will be occasions when it is impossible to keep certain appointments. Therefore, we request that you call our office and advise us of the need to cancel an appointment as far in advance as possible.

3. If a trend develops in the treatment of your child which shows that appointments that are needed are not being made, or multiple cancellations of appointments are taking place, then we will no longer be able to treat your child. In that event, your child will be terminated as a patient of this practice.

We look forward to having your child in our care, and hope that you will assist us in seeing that our policy for scheduling of appointments is complied with. Please digitally sign below indicating that you have read the preceding policy and have had the opportunity to have any questions concerning this policy answered. You are also indicating that you agree to have your child accepted as a patient under the terms of this policy.

Due to the number of patients who have not shown up for appointments or cancelled less than 24 hours before their appointments, Elizabethtown Dentistry for Children is initiating a fee for repeat offenders as of January 1, 2018. While we understand that last minute emergencies do occur, we cannot continue to cover our costs if this occues repeatedly! Every patient will be given a free missed appointment/last minute cancellation every year. Beyong this one time, a $20/child fee will be charged for missed appointments and cancellations that occur less than 24 hours in advance. This fee MUST BE PAID before a new appointment will be scheduled. As always, we value your children and feel honored to serve our patients in a more timely fashion by cutting down on unused appointments!

It is the policy of this dental practice to inform parents of all procedures contemplated for your child. At each examination appointment, we will identify the dental treatment needed and describe this to you and your child. Each regular examination visit consists of oral hygiene instructions, cleaning of the teeth, topical application of flouride, radiographs (x-rays) if needed, and examination of the teeth, the soft tissues of the mouth and each individual's bite. Any other treatment needed such as fillings, caps, extractions, etc., will be performed at a SEPARATE visit after obtaining you or your representative's permission.

State law requires us to obtain your written informed consent for treatment given to your child as a legal minor. WITHOUT WRITTEN CONSENT, THE LAW PREVENTS OUR

OFFICE FROM SEEING YOUR CHILD.

1.) I hereby authorize and direct the dentists of Elizabethtown Dentistry for Children and their dental auxiliaries, to perform any needed dental treatments, including the use of any needed local anesthesia ("numbing"), radiographs or diagnostic aids.

2.) "Dental Treatments" may include, but are not limited to:

-Cleaning teeth and applying flouride

-Application of the plastic protective sealants to grooves

-Removal of cavities and replacing form and function with white/silver filling or silver caps

-Extractions (pulling of teeth & nerve treatments of teeth).

-Treatment of crooked teeth or other oral development or growth abnormalities

-Use of local anesthesia, by injection, to numb the teeth to be worked on to prevent pain. Numbness usually lasts 1-3 hours.

-Use of nitrous oxide ("laughing gas") to reduce anxiety and pain. This gas is placed over the child's nose. This gas is very safe at the concentrations we use, and truly our most valuable tool in treatment of your child!!

-Use of Behavior Management techniques such as Tell-Show-Do, Firm Voice control, and positive reinforcement. We do not use physical restraint in our office, but may ask legal guardians of our staff (WITH LEGAL GUARDIANS PRESENT) to hold hands to prevent a child from unknowingly hurting themselves.

I fully understand that there is a possibility of surgical and/or medical complications that develop during or after a procedure, in spite of every precaution. These risks and side effects may include adverse reactions to drugs that may cause hospitalization, further surgical procedures, disability, system impairment, permanent or temporary nerve damage or death. I further authorize the dentists of Elizabethtown Dentistry for Children to perform any emergency treatment needed to preserve the health and life of my child.

I hereby state that I have read and understand this consent and behavior management techniques and that all questions about the procedures have been answered in a satisfactory manner. I also understand that I have a right to be provided with answers to questions that may arise during the course of my child's treatment.

I further understand that this consent will remain in effect until I choose to terminate it.

PURPOSE: This form is used to document an individual's consent for treatment and acknowledgement of receipt of our Privacy Practices Notice or our good faith, but unsuccessful effort to obtain that acknowledgement. We are not obligated to attempt to obtain this acknowledgement in an emergency treatment situation.

SECTION A: Individual receiving Privacy Practices Notice

SECTION B: Consent & Privacy Practices Notice of Acknowledgement

I hereby consent to the Practice of Elizabethtown Dentistry for Children (The "Practice") using or disclosing my protected health information for the purpose of Providing treatment to me, obtaining payment for health care services rendered to me, or to carry out the Practice's health care operations. I also consent to the Practice using or disclosing my protected health information for treatment activities provided by another health care provider or entity. I further consent to the disclosure of my protected health information in order for another provider or health care entity to conduct health care operations including quality assessment and reviewing the competence of health care professionals.

I further acknowledge the Practice has provided me a copy of it's NOTICE OF PRIVACY PRACTICES, which provides a detailed description of the uses and disclosures allowed by this consent, as well as other rights I have regarding my protected health information.

**If this authorization is signed by a personal representative on behalf of the individual, complete the following two fields:

THE FOLLOWING HAVE PERMISSION TO BRING CHILD FOR TREATMENT AND MAKE TREATMENT DECISIONS:

Guardian: I certify that I have read and understand the questions, above. I acknowledge that myquestions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that | have made in the completion of this form.

--- FOR OFFICE STAFF ONLY ---

SECTION C: Good faith effort to obtain acknowledgement (complete only if you fail to get individual's signed acknowledgement on this form or otherwise)

SIGNATURE OF AUTHORIZED PRACTICE REPRESENTATIVE:

I attest that the above information is correct.

Include completed form in the individual's records. Send copy to the Privacy Official.