Simply Smile & Stand Out

Patient Consent Form 

I understand that I have certain rights of privacy regarding my protected health information.. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  • Obtaining payment from third-party payers (e.g. my insurance company)
  • The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. 

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing at any time. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.


Brandon 813.681.9473
Plant City 813.759.9474
Fishawk 813.643.9473


Orthodontics & Pediatric Dentistry Under 18










I, the undersigned parent/legal guardian, authorize Busciglio Smiles and their staff to examine this child, clean his/her teeth, perform necessary dental treatment, administer local anesthetics, administer medications, apply topical fluoride, obtain study models and other records necessary for an accurate diagnosis for my child. I further request and authorize the taking of dental radiographs (x-rays) as may be considered necessary by Busciglio Smiles 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. Busciglio Smiles will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, using variable voice tone, mouth props, nitrous oxide (laughing gas), or protective stabilization when necessary to promote cooperative behavior and a positive experience and to protect my child from potential injury. 


We reserve your appointment time specifically for you. If you need to reschedule, please give us at least 24 hours notice so that we may give someone else the opportunity to use that time. A fee, up to $50, may be charged for late cancellations (less than 24 hour notice) and/or missed appointments. This fee must be paid before a new appointment is scheduled. If your child is under the age of 6 we ask that you schedule a morning appointment. Younger children often respond better to new environments when they are well rested.  


Thank you for choosing our office as your child's dental provider. We are committed to providing you with the highest quality lifetime dental care, so that your child may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment. Payment is due at the time service is provided. Our office accepts most major credit cards.

Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance, you will be responsible for any collection and/or legal charges up to 35%

Do You Have Insurance? 

  • As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. 
  • All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract. 
  • Our practice is committed to providing the best treatment for our patients and our fees are usual and customary for our area. You are responsible for payment re-gardless of any insurance company's arbitrary determination of usual and customary rates. 
  • We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office (assignment of benefits to the provider). 
  • We ask that you pay the deductible and co-payment, which is the estimated amount not covered by your insurance company, by credit card at the time we provide the service to the patient. 
  • Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time. 
  • We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

    We thank you for the opportunity to serve your child's dental health care needs and welcome any questions you may have concerning your child's care or our financial policy.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO Busciglio Smiles. I understand that responsibility for payment for dental services provided in this office for my dependents is mine, due and payable at the time services are rendered. I further understand that a finance, rebilling, collection charge and/or attorney fee will be added to any overdue balance.

Ortho-Pedo Form

Authorization for Others to Consent
to Dental/Orthodontic Care
I hereby give permission for:

To bring my child(ren) into this office for dental care. This includes, but is not limited to, examinations, orthodontic care, dental cleanings, fluoride treatments, x-rays, and restorative care, extractions, space maintainers, and the use of nitrous oxide. He or she also has my authorization to make any decision for the medical care of the child based on Dr. Derek Busciglio and/or his associates recommendation(s) regarding treatment in my absence. I agree to assume financial responsibility for his/her decisions. I also give permission for those named above to have any Ortho/ Dental treatment/Medical History reviewed and discussed.

This consent is valid from date signed until revoked by parent or legal guardian.

This consent is valid for the child(ren) listed:


Brandon 813.681.9473
Plant City 813.759.9474
Fishhawk 813.643.9473