If the child is under 18 years of age, we expect a parent of guardian to remain in the office for the child's entire visit.
Person Responsible For Account
Who is accompanying the child today?
Has the child had/experienced any of the following:
Is the child allergic to any of the following?
Does/did your child have any of the following habits?
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 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.
DUE TO THE INCREASED NUMBER OF BROKEN APPOINTMENTS THERE WILL BE A CHARGE OF $50.00 PER ½ HOUR OF APPOINTMENT TIME
BILLED TO YOUR ACCOUNT FOR MISSED APPOINTMENTS WITHOUT 48 HOURS NOTICE. WE WILL TRY TO CONFIRM APPOINTMENTS THE DAY
PRIOR TO YOUR SCHEDULED TIME. WHEN YOU MAKE AN APPOINTMENT IT IS YOUR RESPONSIBILITY TO KEEP IT. HOWEVER, IF WE
CANNOT REACH YOU OR YOU DO NOT GET THE MESSAGE, THE APPOINTMENT IS STILL YOUR RESPONSIBILITY.