I understand that the information that I have given today is correct to the best of my knowledge. I understand that it is my responsibility to inform this office of any change in my child's medical status. I understand that I am responsible for payment of services rendered and also for paying any co-pay and deductible that my Dental Benefit does not cover on the date of service. We schedule your time for your child and for your child only. Because of this, there will be a charge of $55.00 per ½ hour of appointment time billed to your account for missed appointments without 48 hours notice. We will try to confirm appointments 1-2 days prior to your scheduled time. However, if we can not reach you or you do not get the message, the appointment is still your responsibility.