I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in this child's medical status. I request and authorize the Doctors at Androscoggin Dental Care and their staff to examine, photograph, clean, and provide my child with comprehensive dental treatment including fluoride application, fillings, sealants, crowns, endodontic treatment, extractions, space maintainers and nitrous oxide if required. I further request and authorize the taking of dental x-rays as may be considered necessary to diagnose and/or treat my child’s dental condition. I will allow photographs to be taken of my child and/or my child’s teeth for diagnostic or educational purposes.
I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. This practice will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation, and demonstration of procedures and instruments, and using variable voice tone. I agree that I will remain in the waiting room and on-site during the child's dental appointment.
I understand that I will be responsible for any charges incurred on this child for dental treatment. Payment is due at time of service unless prior arrangements have been made. I understand that I am responsible for any charges incurred on this child for dental treatment, as well as any copay and deductibles that my insurance does not cover.