Private Statement

Your privacy is very important to us. No information obtained will ever be shared with anyone other than your insurance company, unless required by a court order.
Adriana Rick, DDS

Recognition of Receipt of Privacy Practices

• You may refuse to sign this recognition.

• By signing, you acknowledge that you have received and understood the office’s Privacy Notice.

• A copy of this notice is available upon request.

Signature & Information

• Signature: ____________________

• Date: ____________________

• Print Name: ____________________

For Office Use Only
If acknowledgement could not be obtained, it may be due to:

• Patient refusal to sign

• Communication barriers

• Emergency circumstances

• Other reason

Parent Authorization, Liability, and Agreement

Permission for Treatment

As a parent/guardian, I authorize Dr. Rick and her team to provide necessary dental care for my child(ren), including:

• X-rays

• Examinations

• Anesthetics or sedatives

• Dental treatment under supervision

This authorization remains in effect until cancelled in writing by me.

Authorized Individuals to Bring Child:

• Name / Date of Birth / Relationship

Financial Liability

• I accept financial responsibility for all dental treatments and medications.

• Payment is expected on the date of service.

• I authorize the release of necessary information to ensure payment.

• I understand insurance may cover less than the total bill, and I am responsible for any remaining balance.

Statement of Principles

• Cancel or reschedule appointments at least 24 hours in advance.

• Being 10 minutes late or more results in a lost appointment.

• Two missed appointments will result in dismissal from the practice.

• Respectful timeliness ensures smooth scheduling for all patients.

Recognition

By signing, I confirm that:

• I understand and agree with the above statements.

• I have provided accurate information about my child’s health.

• I will notify the office of any changes to health, safety, or contact details.

• All authorizations remain valid until I cancel them in writing.

Healthy Smiles Rules

To ensure the best care and a safe environment:

1. Parents are not permitted in the operatory. If the child becomes distressed, parents will be called back immediately.

2. Children over 5 years old must remain in the waiting room.

3. Multiple children with appointments may be seen at the same time, but not in the same room.

4. Please avoid bringing extra guests or children to appointments.

5. Phone use, including calls and video recording, is not allowed in treatment areas.

6. After two missed appointments (no-shows), we will no longer schedule future visits.

7. If cavities are found, treatment must be scheduled for another day (often up to one year later due to demand).