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Los Gatos Pediatric Dentistry

15827 Los Gatos Blvd, Ste B,
Los Gatos, CA 95032
(408) 356-4900

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Parent/Guardian 2 Information( * mandatory to fill )
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IS YOUR CHILD

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Has your child had any of the following?

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CONSENT:

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.

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PLEASE ENSURE ALL NECESSARY INFORMATION IS PROVIDED FOR THE INSURANCE POLICYHOLDER BEFORE MOVING ON TO THE NEXT PAGE.

For any changes to an appointment, please note that we do 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 is begun. 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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