Patient Information



Male Female

Getting to know you

Yes No

Who may we thank for referring you to our office?

Doctor or Patient or Other

Account Information

Please be sure all blanks are filled in.

Insurance Information

Mom Dad
Mom Dad

Parent Information

If you would like us to contact you through your e-mail address, please supply below: 

Patient's Name  Date of Birth   Date 

Directions: Please circle appropriate answers and fill in blacks. If you don't know an answer circle "(?)"


    Does the child have any history of the following?

Is the child currently under the care of a physician? 

Has the child ever been hospitalized? 
Has the child been treated in the emergency room? 
Is there any additional medical information about the child not reported above? 


Has the child had any of the following dental problems?
Does the child have any of the following habits?


Which of the following best describes the child?
Your child is a minor; therefore, it is necessary that signed permission be obtained from a parent or guardian before any den tal care can begin.
I acknowledge that the above information is correct and grant this office permission to provide my child's dental and related medical surgical treatment as deemed necessary, utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete same treatment, including diagnostic radiographs. If my child ever has a change in his/her health or his/her medications change, I will inform the doctor at the next appointment without fail.
Dentist's remarks:

Galaxy Smiles Children’s Dentist and Braces
9575 W. Tropicana Ave. Suite # 5
Las Vegas, Nevada 89147
(702) 633-8331

Consent for Treatment


1. I hereby authorize and direct Galaxy Smiles Children’s Dentist and Braces to perform on my child necessary dental treatment as presented in the treatment plan, including the use of necessary or advisable local anesthesia, radiographs (x-rays), diagnostic aids, and/or nitrous oxide.

2.I have read the preceding information regarding behavior management techniques and understand that at times it may be necessary for the dentist to utilize these management techniques; I can discuss them with the dentist prior to treatment.

3. I understand that specific dental/surgical procedures will be explained when I am presented his or her treatment plan. Alternate methods, if any, will also be explained to me, as will the advantages and disadvantages of each. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and, therefore, there can be no guarantee, expressed or implied, as to the result of the treatment or as to cure.

4. Although their occurrence is infrequent, there are some inherent risks that accompany dental procedures.
  A. Local anesthetic (such as Lidocaine or Novocaine) is used to make teeth numb so that dental treatment will not hurt. When it is used, the child may chew the cheek, lip or tongue while they are numb. Soreness of the lower jaw (trismus) may also occur following an injection.
  B. Although not common, excessive bleeding, pain or swelling may occur following removal of a tooth. Temporary or permanent numbness of the tongue or lip (paresthesia) can also occur.
  C. Nitrous oxide (laughing gas) is used to help relax children who are particularly nervous so that the treatment can be done properly. Though infrequent, the child may experience nausea or vomiting with its use.

I hereby state that I have read and understand this consent, and that all questions about the proceclure(s) have been answered to my satisfaction. I understand that I have the right to be provided with answers to questions that 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.

 Patient's Name 


Privacy Rule Patient Consent Agreement

I    understand that as part of my health care, Pediatric Dental Care (PDCA) originates and maintains health records describing my health history, symptoms, examination and test results, diagnose, treatment and any plans for future care or treatment. I understand tha this information serves as:
  • A basis for planning my care and treatment
  • A menas of communication among the health professionals who may contribute to my health care
  • A source of information for applying my diagnosis and surgical information to my bill
  • A means by which a third-party payer can verify that services billed were actually provided
  • A tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals

I have been provided with a copy and understand the Notice of Information Practices that provides a more complete description of information uses and disclosures

I understand that:

  • I have the right to reivew the PDCA's Notice of Information practices prior to signing this consent
  • That PDCA reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I've provided if requested
  • I have the right to object the use of my health information for directory purposes
  • I have the right to request restrictions as to how my protected health informations may be used or disclosed to carry out treatment, payment or healthcare operations and that PDCA is not required by law to agree to the restrictions requested
  • I may revoke this consent in writing at any time, except to the extent that PDCA has already taken action in reliance thereon

I requested the following restrictions to the use or disclosure of my protected health information


Patient Financial Responsibility

We are pleased to welcome your child as a new patient. To prevent any misunderstandings regarding payment for your child s treatment, please review and sign the following policy.
After the examination of your child is completed you will be given a printed summary of the projected treatment along with an estimate of the anticipated fees.


For your child s first visit, if insurance can not be verified, full cash payment is required at the time of services are rendered.

We will attempt to verify your dental insurance coverage at or before your first visit. We can file insurance claims as a courtesy to you. Please remember however, that you, the parent, are ultimately responsible for payment on the account, NOT your insurance company. You must pay your deductible, co-payment, and fees for services not covered, at the time treatment is provided. You are still responsible for these fees even if you have double insurance coverage. We do not routinely bill secondary insurance companies. This is the patient s responsibility.

We can only make estimates regarding insurance company payments based upon the information that is given to us at the time of verification.

While we do our best to collect all fees due from your insurance carrier, fees not paid by the carrier within 60 days are due and payable by the patient.


Payment is due at time of service. Any cash balance over 60 days is subject to a finance charge of 1 1/2% per month. We offer "Care Credit" patient payment plans.

If your account remains unpaid past 90 days, it may be sent to a collection agency for non¬payment and/or delinquent matters. All accounts sent to collections are subject to a collection agency fee and possibly other legal costs in addition to the balance that is owed. If you have any questions regarding this policy, please ask us.

The parent or guardian who accompanies the child is responsible for payment. I have read and understand the contents of this agreement. I agree to comply with all policies.

I have read and understand the contents of this agreement. I agree to comply with all policies.



Our desire is to provide quality treatment in a caring environment for you and your child. We provide the following information in order to familiarize you with our office policies. Please feel free to discuss any questions you may have with a member of our staff.

We ask that parents accompany their child back to the examination room for their first visit. A complete diagnosis and any necessary x-rays will be completed. The doctor will discuss his diagnosis and recommend a plan of treatment. On subsequent visits, we ask that parents remain in the reception area and your child will be taken to the treatment area alone. We have found that we are better able to establish a rapport and keep all of our attention focused on the child when the parent is not present. One of our dental assistants will remain with your child at all times. When treatment has been completed the dentist or a dental assistant will explain to you what was done, as well as what the next treatment will involve. At any visit if you wish to speak to the dentist about anything, please tell the dental assistant and the doctor will be happy to meet with you.

We utilize a number of behavior management techniques to help children through their treatment. All of the techniques we use are recognized by the American Academy of Pediatric Dentistry as effective and acceptable. Our goal is to provide the treatment in an efficient, safe manner while hopefully instilling a positive dental attitude in the child.

During treatment, nitrous oxide (laughing gas) is frequently used to reduce anxiety. (We call the small rubber mask *Mr. Nose'). Nitrous oxide is very safe, has few side effects with the exception of nausea in a small percentage of children, and has no lingering effects after the visit. For our especially fearful patients, the doctor may suggest that your child be given a mild sedative prior to treatment. This premedication is generally liquid Demerol and Atarax given orally one hour prior to the appointment as a sedative and relaxant. Our goal is not to put your child to sleep; rather, to help relax them and make him or her feel happy and more comfortable with the visit.

In order to provide quality dental work and reduce the risk of injury to a child, it is absolutely necessary that the child remain still during treatment. Despite our efforts to calm a child with reassurances, showing the instruments and explaining the noises they will hear, at times we encounter difficult management problems. If a child is cooperating poorly it may be necessary to use one or more of the following behavioral management techniques to facilitate treatment.

VOICE CONTROL: In order to gain the child's attention, instruction is given in a firm tone of voice.

IMMOBILIZATION: So the child does not cause injury to themselves by trying to grab the doctor's hand during treatment, some children may need to have their hands held by an assistant during certain parts of the procedure to help them sit still. If a child is too young to understand the importance of sitting still (usually 3 years of age or less) or if they are endangering themselves with a lot of uncontrolled movement, they may need to be placed in a pediatric wrap which is sometimes referred to as a, 'papoose board'. A pediatric wrap is on display in each examination room. The wrap, or papoose board, holds the head and wraps the arms and legs securely in a blanket fastened with Velcro closures. This is used as a last resort in order to provide motion control so your child is protected during dental procedures. It is not used as punishment. In the event we feel the wrap must be used, we will notify you at that time, before placing the child in the wrap. You will have the option of giving or denying us permission to use the wrap. If you decline the use of the papoose board it will likely mean that no further treatment can be rendered that day and it may then be necessary to consider hospitalization for future treatment.

HOSPITALIZATION: This may be recommended for very young children or those children with significant medical or behavioral problems. This is required for very few children and will be thoroughly discussed with you if other options can not be used successfully.

Your child's best interests are most important to us. We will seek to conservatively manage the behavior of your child and help him or her to accept dental care in a positive, non-threatening environment. We hope to promote good, long-term attitudes toward dentistry, oral health, and self. Thank you for trusting us to treat your child.

About Your Insurance

Dental insurance can be a big help to most families by helping to cover some of the fees associated with dental treatment. However, dental insurance plans are usually very different from most medical plans. We hope the following information will give you a better understanding of dental insurance.

1. There are literally hundreds of dental insurance plans and each is different. It is not possible for us to know what procedures your insurance does and does not pay for when we recommend our treatment based upon what an insurance company will pay. We recommend treatment based upon what we feel is in your child's best interest.

2. We can provide an estimate of what your insurance may pay, and what your copay may be, but it is only an estimate. Sometimes proposed treatment can change which may increase or decrease the amount due from insurance and/or, you. Reimbursement depends on the yearly maximum amount balance of your insurance plan. The yearly maximum is usually from $750.00 - $1,500.00. It is your responsibility to know this amount and what you have already used. You are liable for any unpaid balance that your insurance has not paid.

3. As a courtesy we will bill your primary insurance for dental treatment provided, but as a general rule, we do not bill secondary insurances. We will be happy to give you a receipt so that you may submit your claim to your secondary insurance. If our office has a contractual obligation to your secondary insurance carrier as a PPO provider, we will submit a claim directly to them for you,

4. You, the parent or guardian, not the insurance companies are ultimately financially responsible for the payment of charges for treatment rendered. If an insurance company denies payment for treatment or procedure you are responsible for the denied amount of the claim.

5. You are responsible for giving us accurate insurance information. When information is inaccurate it may delay treatment, authorization, or payment, which could lead to you having more out-of-pocket expense.