Pediatric Dental Specialists - Patient Update
Patient's Name
X-rays may be taken as part of today’s dental examination. I UNDERSTAND that the doctor’s recommendation for x-rays is based on my child’s individual needs and NOT on what the insurance company determines they will cover. I assume financial responsibility for the cost of x-rays should my insurance company deny payment.
Yes
No
****If there is any reason why your child should not have x-rays taken today, please notify us.****
Has there been any change in your child’s health since your last visit?
Yes
No
If so, please explain
Is your child currently under the care of a physician and/or taking any medication(s)?
Yes
No
If so, please explain/list all medications:
Has there been any injury to your child’s teeth, head, or neck since his/her last visit?
Yes
No
If so, please explain:
Are there any questions or concerns you wish to bring to the doctor’s attention at this visit?
Yes
No
If so, please explain:
Has your child been seen by an orthodontist and if so, have recent x-rays been taken?
Yes
No
Orthodontist’s name and city
FAMILY RECORD UPDATE
Pediatric Dental Specialists may use my cell phone number to call or text regarding appointments, treatment, insurance, and my account. I understand that I can withdraw my consent upon written request.
I consent to this statement.
Yes
No
Initials:
My cell phone number, e-mail, address and home phone numbers on file are all current and do not need to be updated.
Yes
No
Updated cell:
Updated email:
Updated mailing address:
INSURANCE INFORMATION
There have been no changes to my insurance since our last visit here
Yes
No
I have new insurance
Yes
No
Subscriber’s Name
Insurance Company Name
Date of Birth
Insurance Phone #
Social Security or ID #
Group #
Employer
This is dual insurance coverage
Yes
No
SECONDARY INSURANCE INFORMATION
Subscriber’s Name
Insurance Company Name
Date of Birth
Insurance Phone #
Social Security or ID #
Group #
Employer
FINANCIAL AGREEMENT
All accounts are due and payable at the time services are rendered, unless prior arrangements have been made. The total fee is your personal obligation. However, if you have dental insurance which will cover the services rendered, please be sure you have informed our office. As a courtesy, we will file the necessary insurance claim for payment on your behalf.
We will help expedite your claim so that you receive the correct amount to which you are entitled under the terms of your policy. The difference (if any) between amounts paid by your insurance (where there is an assignment of benefits) and the amount billed is your responsibility.
I have read the above and I understand that I am responsible for all charges incurred.
By signing below, I certify that I have completely read, understand as well as agree to the above statement(s)herein:
Signature
Date
Relationship to Child
Submit
