These questions are of great value in aiding us in the treatment and better understanding of your
child/teen, medically, dentally and socially.
If you choose to drop off your child or teen at our office for their dental appointment, you must meet the following criteria:
I certify that I have read and understood the above medical and dental questions. I will not hold Dr. Bass Allen or any member of her staff responsible for any errors or omissions I may have made in the completion of this form.
I hereby consent to the performance of Dental Services upon this patient. Services include exam, cleaning, fluoride, anesthetics, sedatives, fillings, extractions or necessary x-rays as may be deemed necessary and advisable by the Doctor. Any and all necessary treatment will be discussed with the parent or guardian before beginning.
I ALSO AGREE TO BE FINANCIALLY RESPONSIBLE FOR ANY TREATMENT, WORK PERFORMED OR MISSED APPOINTMENTS. PAYMENT IS EXPECTED AT THE TIME OF SERVICE.
If I have dental insurance to help pay for my child’s dental care, I agree to be financially responsible for any portion my insurance company does not cover. I also agree to pay finance charges on any balance due over ninety (90) days. I also agree to reimburse the dentist for any reasonable attorney fees and costs incurred in the collection of my delinquent account, if necessary.
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