4. Has your child has fluoride in any of the following forms?
9. Have your child’s teeth ever been injured?
10. Does your child have any of the following habits? (Indicate ages when occured)
In order to control the cost of dental services, we require that payment be made at the time of service, unless otherwise discussed previously with our Financial Coordinator. Payment can be made with cash, personal check, MasterCard or Visa. if for any reason your check is returned to us, there will be an additional fee.
Please indicate the person responsible for payment:
AUTHORIZATION AND RELEASE
CONSENT FOR TREATMENT
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dentist to release any information including the diagnosis and the record of treatment or examination rendered to my child during the period of such care to third party payers and/or health practitioners. I authorize the use of radiographs and photographs for the purpose of teaching and scientific publications. I request that my insurance company pay directly to the dentist. I understand that my insurance carrier may pay less that the actual bill for services; therefore, I agree to be responsible for payment of all services rendered on my child’s behalf.