PAGE 1: PEDIATRIC DENTISTRY CONSENT FOR DENTAL PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION
Please read this form carefully. If you do not understand something to your satisfaction please ask questions. We will explain it.
I hereby authorize and direct Dr. Stephanie Chen, assisted by dental auxiliaries of her choice, to perform the following dental treatment which, in general terms, the dental procedure(s) or operation may include:
This treatment will be explained to me by Dr. Chen, the hygienist or dental assistant. Alternative methods of treatment, if any, will also be explained to me. I am advised that, though good results are expected, the possibility and nature of complications cannot be completely anticipated. Therefore, there can be no guarantee as expressed or implied either as to the result of the treatment or as to the cure. I further authorize Dr. Chen to perform other dental services that, in her judgment, are advisable for my child or legal ward.
I hereby state that I have read and understand this consent, and that all questions about the procedure or procedures have been answered in a satisfactory manner and I understand that I have the right to be provided with answers to questions which may arise during the course of my child's treatment.
I further understand that this consent will remain in effect until such time that I choose to terminate it.
Sign above using mouse or touch
Sign above using mouse or touch
Sign above using mouse or touch
PAGE 2: FINANCIAL POLICY
PAYMENT POLICY: Please be aware that the parent/guardian bringing the child to the appointment is legally responsible for the payment of all charges. This parent/guardian will be responsible for all the fees regardless of any custody agreements or court orders. This office will not be involved in any custody disputes, financial or otherwise. All appointments either cancelled or broken within 24 hours will incur a $60.00 fee.
We operate on a fee for service basis; therefore a payment will be necessary at every visit.
Payment options if you are self pay:
- A. You may choose to pay by cash, check, or MasterCard/Visa.
- B. On treatment involving laboratory fees(bridges,orthodontic appliances) you may choose to pay 50% on the preparation date and the balance on the delivery date.
- C. All dental treatment is expected to be paid in full at the time of service.
Payment options if you have insurance:
- A. Dr. Chen is not a participating provider with insurance, therefore, co-pays and reasonable and customary charge acceptance does not pertain in any way to this office.
- B. We can file some insurance claims, as a courtesy; however, the patient is responsible for the balance on account if insurance has not paid within 60 days. We will help in any way to speed the processing of all claims. As Dr.Chen is not contracted with any insurance company, it is the parents responsibility to follow up with the insurance carrier and maintain current/updated information with our office.
- C. If your insurance carrier is a reimbursment, you may pay according to self pay options.
- D. If you have new insurance and do not have the information for our office to file your claim, payment will be expected in full for services and you will be provided with a standard dental claim to file for reimbursment.
Insurance is a contract between you and your insurance company. Please be aware of the benefits of your policy. Although we may estimate what your insurance company may pay, it is the insurance carrier that makes the final determination of payable benefits.
If you have any questions concerning these policies, please do not hesitate to ask our administrative staff.
Once you have signed this agreement, you agree to all of the terms and conditions contained herein.
Sign above using mouse or touch
PAGE 3: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received a copy of the Notice of Privacy Practices for the above named practice.
Sign above using mouse or touch
FOR OFFICE USE ONLY
We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
Sign above
Notice of Privacy Act available upon Request
