Dental Insurance Company’s Name
All fees for services rendered are payable at the conclusion of each appointment unless other financial arrangements have been made. I agree to be responsible for payment of all services rendered for this child. If applicable I authorize my Insurance Company to pay directly to Dr. Morrow, Dr. Jamison and/or Dr. Beville. In understand that my dental insurance carrier may pay less than the actual bill for services and that I am responsible for the balance.
IV. Care of Parents:
At the first visit the teeth are cleaned then x-rayed for children over 3 years of age. If the child is suffering from a toothache, emergency treatment will be provided. No fillings or extractions will be done on the child’s first visit. An account of the services to be rendered and cost of the complete case will be given to the parent before any treatment is begun.
In providing dental care, we will treat your child as we would our own. Numbing agents and dental gas are used routinely to help overcome the feat of dental care. Dentistry is an important health service for your child, and we will attempt to provide your child a satisfying experience in our office.
V. Consent for treatment of a minor:
The undersigned hereby authorizes Dr. Morrow, Dr. Jamison and/or Dr. Beville to perform the examination including x-rays, and after explanation, all forms of treatment, medication, and therapy indicated for the dental care of the above named child. This consent shall remain in force and effect until cancelled by either party.