Let's Get Acquainted PATIENT INFORMATION

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Let's Get Acquainted PATIENT MEDICAL HISTORY

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IS YOUR CHILD

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  •  AIDS
  •  ANEMIA
  •  ASTHMA
  •  BIRTH DISEASE
  •  BLADDER DISEASE
  •  BLOOD DISEASE
  •  BLOOD TRANSFUSION
  •  BRONCHITIS
  •  CANCER
  •  CEREBRAL PALSY
  •  CHICKEN POX
  •  CONVULSIONS
  •  DIABETES
  •  DRUG PROBLEMS
  •  EPILEPSY
  •  FAINTING
  •  HEARING PROBLEMS
  •  HEART DISEASE
  •  HEMOPHILIA
  •  HEPATITIS IN FAMILY
  •  HIV-POSITIVE
  •  KIDNEY DISEASE
  •  LIVER DISEASE
  •  MALIGNANCIES
  •  MEASLES
  •  MONONUCLEOSIS
  •  MUMPS
  •  PSYCHIATRIC TREATMENT
  •  RHEUMATIC FEVER
  •  SCARLET FEVER
  •  SINUS INFECTION
  •  THYROID
  •  TUBERCULOSIS
  •  OTHER
  •  NOT APPLICABLE

Let's Get Acquainted Parent/Guardian 1 Information

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Let's Get Acquainted Parent/Guardian 2 Information

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Let's Get Acquainted INSURANCE & ACKNOWLEDGEMENTS

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Please complete this page with as much information from your dental insurance as you can.

If you are uncertain as to where to find the neccessary information, we recommend contacting your dental insurance provider to retrieve all required information before your appointment.

Your child’s examination will include a complete oral exam and X-ray diagnosis. A dental cleaning will be performed along with a fluoride treatment. If any additional treatment is necessary, it will be discussed with you prior to performing such treatment. Payment is due at time of service.

 

We require a minimum of 24 hours notice for cancellations. A fee of $75.00 is applied to your statement for same-day cancellations ($100.00 for treatment appointments). Financial arrangements will be made with the receptionist before dental treatment begins. A 15% monthly service charge on your balance over 90 days (18% annual interest) will be charged. For your convenience, we accept all major debit and credit cards.

By signing below, you understand and accept the above terms, and confirm all information provided is true and correct to the best of your knowledge.

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