First Time Patient

Child's Gender: * Male
Female

Do you have legal custody of this child? * Yes
No

Is this phone number your? * Home
Work
Cell

Is this phone number your? Home
Work
Cell

Phone number is: Home
Work
Cell

Phone number is: Home
Work
Cell

Dental Insurance: * Yes
No

Secondary Dental Insurance: Yes
No

Medical Insurance: Yes
No

We would like to remind you about your appointment. What methods would work best for you? * Email
Text
Phone

Is your child in good health? * Yes
No

Is your child allergic to Nickel: Yes
No

Is your child allergic to Latex: Yes
No

Is your child currently taking any medications? * Yes
No

Has your child ever been hospitalized? * Yes
No

Does your child need to be pre medicated with antibiotics before dental treatment? Yes
No

Has your child experienced clicking sounds or pain of the jaw joints upon opening/closing of the mouth? Yes
No

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 that it is my responsibility to inform this office of any changes in my child's medical history. I authorize the Doctors and the staff at Bel Air Pediatric Dentistry to perform necessary dental services associated with my child's dental care. I authorize Bel Air Pediatric Dentistry to submit fees for rendered services to the listed insurance company(s) for payment, I understand that I am responsible for payment of services at the time they are rendered.

If your account shows a balance, you will receive a statement each month, even if insurance has been submitted for you. All fees incurred with this office for services rendered will be due at the time of service unless previous arrangements have been made. If, for any reason, the bill is outstanding after 60 days, a late charge will be added to your balance in the amount of 1.5% per month which is an annual rate of 18%.

Insurance: We will be happy to complete and file your insurance forms to aid you in collecting full benefits according to your insurance plan. Patients who have dental insurance should be advised that the professional services rendered are charged to the patient and not the insurance company. You are responsible for any portion not paid by your insurance company, including any co-payments, deductibles, fees over your insurance company's UCR, etc. Even though an insurance claim has been filed, you will receive a statement each month if your account has a balance due. It helps us get your full benefits if you list complete dental insurance information on the previous page for all insurance plans.

Responsibility: We realize that many families are in a state of change. Divorced, separated, single parent and blended families are now common. In many of these families the question of who is responsible for the child's dental bills is uncertain. In the case of separated or divorced families we will need to have this form signed by the financially responsible party, otherwise the accompanying parent is responsible.

If you have any questions, please feel free to discuss them with the receptionists.

I have read the office policy and request that your office provide dental care. I authorize release of any information relating to any insurance claims. I hereby authorize payment directly to the dentist of the insurance benefits otherwise payable to me.

I understand that by signing this form I am hereby accepting responsibility for any and all fees incurred with this office.

Any amendments to this agreement must be discussed with the office manager and another form signed before any services are rendered. No handwritten amendments to this form will be accepted.

Click here to review our privacy practices.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have reviewed this office's Notice of Privacy Practices from the link above

Consent for treatment
I am the parent/guardian of the minor child. I authorize examination of and treatment as necessary by or under the supervision of Dr. Kapil Davar or Dr. Vidhima Davar at Bel Air Pediatric Dentistry LLC. This includes exposure of radiographs (x rays) as necessary, cleaning, fluoride application, use of local anesthetic and/or nitrous oxide (laughing gas, if necessary), fillings/extractions/ crowns (if necessary) , reasonable restraint as needed, and use of appropriate medicaments and materials for such treatment.

I have read and understand the above information. By my signature below I consent to the treatment described above.

Broken Appointment Policy
We strive to provide excellent care to our families and reserve time specifically for your child to be seen. We understand and try to accommodate the schedules of parents and make every effort to see your child in a timely manner. Therefore we request that you extend us and our other parents the same courtesy by informing the office at least 24 hours in advance if you are unable to keep your appointment. There maybe a $30.00 missed appointment charge per child to your account if you do not provide our office 24 hours cancellation notice. We also reserve the right to terminate professional treatment of any patient who continually fail to keep their scheduled appointments.