If you answer yes to any of the three items above, please stop and return this form to the receptionist.

Please list the name and phone number of the child's physician:

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Acknowledgment of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of KB Dental. I hereby authorize, as indicated by my signature below, KB Dental to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent Form.

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

Assignment and Release
I the undersigned, have insurance with ____________ , and assign directly KB Dental all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.

Patient Agreement and Financial Policy

I hereby agree to be responsible for the costs of care provided by KB Dental and/or the dental team for myself or my dependent(s). These include any deductibles and amounts not covered by insurance. I also understand that it is my responsibility to be aware of any limitations, and benefits of my insurance policy. Payment to this office is my responsibility and I am aware that if the insurance company does not reimburse the doctor within 60 days, I am responsible for the total amount(s ). 

I understand that there will be a $35 charge to all accounts in which a check payment is returned. 

I understand that because appointments are not double-booked, I must provide notice of cancellation at least 48 hours prior to my scheduled appointment time. 

For appointments scheduled for 90 minutes or longer, I will be required to make a reservation fee of $100 prior to scheduling the appointment, which will be applied to my out-of-pocket expense for the appointment. This reservation fee is non-refundable. If I do not show up for my appointment or I do not give adequate notice if I am unable to keep my appointment, the reservation fee will be forfeited. For appointments scheduled for less than 90 minutes, a $50 cancellation fee may apply if I do not provide notice of cancellation at least 48 hours prior to my scheduled appointment time.

We make every effort to schedule appointments that are most convenient for you and that fit your personal schedule. Because we do not schedule several patients at the same time, all appointments are reserved exclusively for you. In return, we ask that you make every effort not to change your reserved dental appointment. 

I understand that for any treatment less than three hundred dollars ($300) payment in full is due at the time of service. I understand that after 60 days, any unpaid balance will incur a $10 billing fee. I understand that failure to pay amounts due to this office will result in my account being placed with a collection agency. In the event that my account is further referred to an attorney, I agree to pay all collection and attorney fees.

Minor/Child Consent

I, being the parent or legal guardian of __________ . do here, by request and authorize the dental staff to perform necessary services for my child, including but not limited to radiographs (x-rays) and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered. I also understand that the parent or guardian who brings my child in for treatment will be responsible for payment unless other arrangements have been made in advance. A receipt will be provided so I may seek reimbursement.

Authorization:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for educational and/or marketing purposes by KB Dental. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations. I understand that I will not receive financial compensation.

Purpose:

My photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising.

Revocability:

I understand that I may revoke this authorization at any time, but such revocation must be in writing addressed to the practice. Revocation affects disclosure moving forward and is not retroactive. This authorization expires _______ years from date signed.