Welcome to Children’s Dental Specialists:
Our office is constantly making exciting changes in order to improve service and
quality of care for your child so that he/she can regain and maintain their dental health as
quickly and efficiently as possible.
Our goal at Children’s Dental Specialists is to get unhealthy mouths well, and to
prevent the well from getting sick. We also have a personal, professional, and ethical
responsibility to care for your child’s dental health to the best of our ability. In order to
provide extraordinary care, we make the following commitments to you:
1. We are an On Time practice. We will see your child on time and get him/her out
on time unless there is an emergency.
2. When we make an appointment, it is an agreement. We prepare a room, have a
doctor or hygienist and an assistant with time devoted exclusively for your child.
No other patient is scheduled in that room at that time.
3. We never perform dentistry unless you understand the treatment and are aware of
the fee.
4. We are very proud of the quality of our work, and we will do our best at all times
to earn the right to your referrals.
In return for our commitments, we need you to make the following agreements:
1. If you are unable to keep an appointment, we ask that you kindly provide us with
a minimum of two business days notice. We prefer to speak directly to you
regarding changes in a reserved appointment, therefore we request you call during
regular business hours. This courtesy on your part will make it possible to give
your appointment to another patient who needs to see the dentist or hygienist.
________ (Initial)
2. Please arrive on time or early for your child’s visits. If you are more than 10
minutes late, we may not be able to complete your child’s appointment.
3. Appointment compliance is critical to your child’s health and avoids setbacks in
the maintenance of your child’s teeth and gums.
REGARDING INSURANCE
For decades dental insurance has been an integral part of oral health planning; however,
in the past few years it has become more difficult for the dental practice to deal with
insurance companies. We are a third party to the contract and the insurance companies
are not obligated to share your confidential policy information with us or required to send
payment to us.
There are constant changes being made by your employer and insurance carriers to your
coverage, deductibles and annual maximum. These changes are not being shared with us.
Therefore, it is impossible for us to know exactly what your policy covers.
In order for us to maintain our high level of service to your child, we provide the courtesy
of submitting the claim on your behalf and supporting you with maximizing your
benefits. However, we are unable to carry your insurance balance for longer than 60
days. Policy coverage, changes and follow-up on unpaid claims is your responsibility.
Please be prepared to show your insurance card at the time of your visit. _____ (Initial)
PAYMENT OPTIONS
Your options include Cash, Check, MasterCard, Visa, and Discover.
ADDITONAL CHARGES
A fee of $_25.00_ will be charged on all returned checks. _____(Initial)
DELINQUENT ACCOUNTS
After 90 days, all accounts that are not paid in full may be sent to a third party collection
agency. If your account is sent to a collection agency, you will be responsible for a
collection fee of 30% of the balanced owed. ____(Initial)
OFFICE HOURS:
Monday
Closed
Tuesday
7:30 AM -- 5:00 PM
Wednesday 7:30 AM -- 5:00 PM
Thursday
7:30 AM -- 5:00 PM
Friday
7:30 AM -- 3:00 PM
I have read, understand and agree to the above Office Policies and Financial Agreement.
____________________________________
PATIENT SIGNATURE
DATE
_______________________________
CHILD’S NAME