PERMISSION FOR DENTAL EXAMINATION

I am the parent or guardian of a minor child and I authorized and consented for this minor to any x-ray, examination, anesthetic, sedative, or dental treatment surrendered under general, direct, or indirect supervision of Dr. Rick and her associates, staff members, or agents, such as he/she may deem necessary. This authorization shall remain in effect until the authorization is cancelled and sent in the form of a letter by me.

I authorize the following people to bring my child to Healthy Smiles PA for treatment.

FINANCIAL LIABILITY

I assume financial responsibility for dental treatments rendered to my child and understand that payment is expected for services from the date provided. I hereby authorize the dentist to release all the information necessary to ensure payment for the treatment. I authorize the use of this signature in all my insurance presentations and direct payment to Healthy Smiles for the dental benefits I’m to pay. I understand that my dental insurance company may pay less than the actual utility bill and therefore am ultimately responsible for paying for the services they do not cover for my child.

STATEMENT OF PRINCIPLES

In order to serve our patients better, we have instituted a declaration of cancellation. If you cannot attend the appointment, please contact us 24 hours in advance to cancel or move the appointment. Failure to keep the appointment causes an inconvenience for employees of the office as well as other patients who may have the opportunity to keep the appointment time. In addition, being late for an appointment causes all subsequent ones to fall behind schedule. It is for that reason, and to respect our patients, that your appointment will be “Lost” if you are ten or more minutes late. The family will be dismissed the second time this occurs. (If you have two children who have an appointment and lose it, it equals two missed appointments.) Your time is valuable, and we do everything we can to respect it. We only ask that the same courtesy be paid to us and other patients to get to your appointment on time.

RECOGNITION

I read, understand, and agree to comply with all the above statements. I affirm that the information I have given in this formulation is correct, and I understand that giving incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s health status, change of safety, or contact information. Finally, all the authorizations I have given will be in effect until I cancel the authorization in a written form.