HIPAA COMPLIANCE & ACCURACY:
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.
FINANCIAL RESPONSIBILITY:
I authorize the dental staff to perform the necessary dental services my child may need. If this office accepts insurance, I understand that I am responsible for payment for services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.