If your child is a new patient, please call our office at (502) 633-4441 to make an appointment before filling out this form. We are not accepting any new Medicaid/Passport insurance at this time.

**If you answered other, you will be required to provide legal documentation.

We are not accepting any new Medicaid/Passport insurance at this time.

I hereby authorize Dr. Kirby Chamber Hoetker, the covering Dentist, or the dental auxiliaries under her supervision to perform any necessary dental treatment upon my child, including but not limited to the use of local anesthetic, radiographs (x-rays) and/or Nitrous Oxide ("laughing gas"). I understand that no services will be performed without my knowledge.
 

Please sign below if you agree to the following statements:
1. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Financial Policy and Appointment / Cancellation policy and I accept all provisions.
2. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Assignment of Benefits Agreement and authorize my insurance company (if any) to pay my dental benefits directly to Pediatric Dentistry of Shelbyville.
3. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Notice of Privacy Practices. I understand that I may refuse to sign this acknowledgement if I do not agree.

If there are other persons you would like to give your permission to bring your child to Pediatric Dentistry of Shelbyville, and to make dental treatment decisions on your child's behalf, please list them below.