Child Registration And History Online Form Melbourne Location

Child Registration And History Melbourne

Phone: (321) 724-4520
1325 Pine St. Suite 103,
Melbourne, FL 32901
  • Child Registration and History

    In order for us to better serve you, please complete this form.
    The information is, of course, confidential and will be protected. Thank you.

  • 1. PATIENT'S HISTORY

  • 2. GENERAL INFORMATION




  • 3. MEDICAL HISTORY

        DOES YOUR CHILD HAVE OR EVER HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?
        *Please Check Health Problems Your Child Have or Ever Had

  • 4. DENTAL HISTORY


  • Because your child is a minor, it becomes necessary that a signed permission is obtained from a parent or guardian before any dental service can be started and accomplished

    PERMISSION FOR DENTAL TREATMENT UPON A MINOR

  • I, being the parent of guardian of the above minor patient, do hereby authorize and request the performance of dental exams and treatment for this patient; I further authorize any dental or behavioral management techniques deemed necessary by your child's treating doctor of staff to complete a course of dental treatment.

    Additionally, I uderstand that office policy dictates that parent/guardians remain in the reception area, and will not be allowed to accompany their child(ren) into the treatment area. This allows us to establish a direct relationship with your child, and is an accepted principle in the practice of children's dentistry.

    I also authorize the administration of local anesthetics or analgesia(nitrous oxide/laughing gas) which may be deemed advisable by the doctor.

    I AUTHORIZED the dentist to release all information necessary to secure payment of benefits. I authorize my insurance company to pay directly to the dentist of dental group insurance benefits otherwise payable to me. I authorize use of this signature on all insurance claim submissions.

    PLEASE NOTE:
    Your appointment is a reservation of space, doctor time, and the time of a number of dental assistants. A $35.00 charge may be made for appointments broken or cancelled without adequate notice. In addition, our office policy requires at least 48 hours notice if a scheduled appointment cannot be kept. Should it be necessary to transfer your child out of our office at some future time, there may be a charge of $24.00 for a copy of the most recent bitewing and panoramic x-rays.