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General Patient Info

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Person Responsible for Account


Secondary Parent/Guardian


Insurance Information

General Information and Consent

Thank you for choosing us to help you keep your child healthy. We are committed to providing specialty dental care for your child. We desire to make your child’s visit both productive and pleasant. The information requested on this form is designed to help us diagnose and treat dental decay (cavities).
Initial Visit: Our goal is to provide a thorough Dento-facial examination including radiographs (x-rays). Today, pending cooperation, we will:



Tooth/gum brushing and flossing instructions will be given to the patient and reviewed with the parent/guardian. We will also discuss dietary recommendations.
Future visits: We will clean your child’s teeth and place fluoride. We will only take radiographs to check for cavities and observe growth, or for other justifiable needs. We employ all procedures available to reduce risk including thyroid/gonadal lead apron, collimated x-ray machine, and the fastest film available on the market today. We follow all the current guidelines recommended by the American Academy of Pediatric Dentistry (AAPD).
Behavior Management: Because of the fear associated with dentistry, it is sometimes necessary to use behavior modification techniques. We employ tell-show-do, voice control, and hand holding. We will not physically restrain your child to obtain cooperation, except in case of emergency. For safety reasons, we do ask that siblings be left in the play area with a responsible adult.
Before your child’s visit please let us know if you object to the use of any of the following:



To better serve you and our other patients,
we ask that you give a 48 hour notice to cancel or reschedule an appointment.
Insurance is filed as a courtesy to our patients; payment is required at time of service.
We accept cash, Visa, MasterCard, Discover and Care Credit.
I consent to the performance of comprehensive dental treatment by Smile Shoppe Pediatric Dentistry doctors and team members. I further authorize any necessary radiographs (x-rays) and photographs needed for the diagnosis and treatment of my child’s dental condition. Comprehensive dental treatment and procedures include examination, teeth cleaning, fluoride application, restorations (fillings), crowns, endodontic treatment (tooth nerve treatment), extractions, and space maintainers. I acknowledge that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age and providing an environment likely to help children learn to cooperate during treatment.

Your Child's Medical Information

1. Is your child currently:
2. Since your child’s last dental visit, has your child:
3. Does your child have, ever had, or been diagnosed since their last dental visit with any of the following: (please check all that apply)
4. Does your child have any other condition not mentioned above?

Your Child's Dental History


I understand the information I have given is correct to the best of my knowledge and will be held in the strictest of confidence. I understand it is my responsibility to inform this office of any changes in my child’s medical status.

Financial Policy

We are pleased to welcome you to our practice. Our desire is to provide you with the highest quality dental care in a caring and enjoyable atmosphere. It is our policy to make definite financial arrangements with you before any treatment starts. Below is an explanation of our payment procedures. If you have any questions, please do not hesitate to ask.

1. Payment for services is due at the time services are rendered. We accept cash, checks, debit cards, and credit cards (VISA, MasterCard, Discover and CareCredit).
2. For new patient emergency visits we require payment in full at the time of the appointment.
3. As a courtesy, we will provide you with a copy of the charges to submit to your insurance carrier for your reimbursement or you may assign the payment to our office and we will file the insurance for you. The office will accept assignment for only the primary insurance coverage, secondary insurance coverage must be paid to the patient.
4. Our office will file your insurance a maximum of two times per appointment.
5. If the claim is not paid by your insurance carrier within sixty days, you will be responsible for the full balance and further insurance appeal becomes your responsibility. We will be happy to provide you with a claim form so that you can follow up on your insurance claims personally.
6. You must provide the office with a dental insurance card with the proper mailing address of the insurance company, or provide a dental claim form, which is provided by the employer. If one of these documents is not available at the time of the appointment, you will be responsible for payment of all fees and we will provide you with a claim form for you to submit for reimbursement.
7. We accept assignment of benefits for a select group of insurance companies; however you will still be responsible for paying your deductible and co-payments at the time of service. You are responsible for paying all charges not covered by your insurance company, including all fees considered above your insurance company’s usual and customary fee schedule. Your insurance benefits are a contract between you and your employer. The amount of coverage you will receive will depend on the quality of the plan purchased by your employer, not the fees of the doctor. We do not allow insurance companies to dictate our treatment planning, but rather what is in the best interest of the child. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary by your insurance company.
8. The office cannot carry balances longer than 90 days; regardless if the insurance payment is still pending. A $5.00 monthly re-billing charge will be added to your account if it is not paid within 60 days, regardless of balance amount.
9. After 90 days, we will inform you of the delinquent account by letter and if no action is taken to clear the account, this office will be required to send your account to small claims court to collect payment. The responsible party agrees to pay all reasonable, related collection fees.
10. There will be a $30.00 service charge for all returned checks.
11. The parent or guardian who brings the child for their initial visit is responsible for payment independent of what a divorce decree may state. Reimbursement must be made between the divorced parents. We will not intervene.
1. I authorize Smile Shoppe Pediatric Dentistry to release any information concerning my case to my insurance company.
2. I have read & accept the above Financial Policy, understand it & agree to the terms set forth regarding payment.

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