REGISTRATION AND HEALTH HISTORY
Has your child had any history of any of the following?
The permission of parent or guardian is necessary for dental treatment of a minor. I give permission to use such measure as deemed necessary in his/her professional judgment to render the best dental treatment for my child. I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child’s health, financial and residential status.
I hereby assign all medical, dental and/or surgical benefits to which I am entitled under insurance, private insurance, Medicaid PA, or other to Cranberry Pediatric Dentistry, PC. I authorize said benefits to be paid directly to Cranberry Pediatric Dentistry, PC. I hereby authorize Cranberry Pediatric Dentistry, PC to release information as required to secure payment of services rendered. I am responsible for and agree to pay all charges for services rendered regardless of whether services are covered by insurance. It is my responsibility to know my insurance benefits. Payment is expected on date of service.
I acknowledge that I have read, understand and may obtain a copy of Cranberry Pediatric Dentistry, PC’s financial policy.
I acknowledge that I have read, understand and may obtain a copy of the HIPAA policy at the office of Cranberry Pediatric Dentistry, PC.