CHILDREN PATIENT INFORMATION WELCOME

RESPONSIBLE PARTY INFORMATION

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EMERGENCY CONTRACT (Specify someone who does not live in your household)

IF BOTH PARENTS SEPARATELY

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DENTAL INSURANCE INFORMATION

Allergies

DENTAL HISTORY

BENEFITS

NOTICE OF PRIVACY PRACTICES

  • 1. The right to inspect and copy your information;
  • 2. The right to request corrections to your information;
  • 3. The right to request that your information be restricted;
  • 4. The right to request confidential communications;
  • 5. The right to report of disclosures of your information; and
  • 6. The right to a paper copy of this Notice.

Acknowledgement of Notice of Privacy Practice

  • In order to be respectful of the medical needs of other patients, please be courteous and call the office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 48 hours in advance. Calling early in the day is appreciated. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.
  • A failure to show up at the time of a scheduled appointment will be recorded in the patient's chart as a "no-show". There will be a fee of $25.00 for regular appointments and $50.00 for any dental cleanings or surgerys. Late cancellations will be considered as a "no-show". Exceptions will only be made in extraordinary circumstances. Cancellations made more than 24 hours in advance of your scheduled appointment time will not be assessed a cancellation fee.
  • Please be sure to arrive at least 15 minutes early
  • In consideration of other patients if you arrive more than 5 minutes late for your or your child’s appointment you may be asked to reschedule.
  • Sonrisas Dental Center does not see patients under the age of eight (7). An adult parent or guardian must accompany all minor patients (under 18 years of age) and must remain on premises, outside the operatory, throughout the appointment. The parent or guardian accompanying the minor patient is legally responsible for any payments due at that appointment.
  • Should you desire to have a grandparent, aunt, uncle or adult sibling accompany your child to their dental appointment, a limited power of attorney, granting that adult the legal authority to make decisions for the child regarding dental issues, is required. This form will also give us legal authority to discuss your child's care with the adult accompanying them and enter into legal contracts with regard to providing services

Authorization For Use Or Disclosure Of Patient
Photographic and/or Video Images