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

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.