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.
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.