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First Name *

Middle Initial

Last Name *

Suffix Select Suffix II III Jr. Sr.

 

General Consent for Treatment:

I hereby give my consent to the dentist and other clinical personnel of Dover Pediatric Dentistry for the evaluation and treatment of my children on an on-going basis. I understand that I have the right to revoke this consent in writing, at any time, except when the physicians or other clinical personnel have already taken action on my consent.

Consent to Treat a Minor: Dover Pediatric Dentistry must have permission from the parent or legal guardian before an evaluation or any medical treatment can be given to a minor.

I, ____________ am the parent or legal guardian having legal custody of born on , I hereby give my consent to the dentist and other clinical personnel of Dover Pediatric Dentistry for the evaluation and treatment of this minor on an on-going basis.

Assignment of Insurance Benefits and other Releases of Medical Information:

I hereby authorize any insurance benefits to be paid directly to the dentist providing services and recognize my responsibility to pay for all non-covered services. I also authorize the dentist or any holder of medical information to release any infonnation necessary to process an insurance claim. l understand that this release of information may include a release to companies that Dover Pediatric Dentistry has contracted with to provide services for Dover Pediatric Dentistry and under those contracts the individuals and companies have agreed to keep any personal health information confidential and to protect it from further disclosure.

Acknowledgement of Receipt of Privacy Practices:

I, the undersigned, understand that Dover Pediatric Dentistry is required by law to maintain the privacy of protected health information and provide me a notice of their legal duties and privacy practices regarding health information about me. My signature below attests that I have read, understood, and agree with the Notices of Office Policy that describes how medical information provided by me may be used and disclosed and how I can have access to this information.

Name of Parent/Guardian
Signature of Parent / Legal Guardian		Relationship	Father Mother Foster Parent Legal Guardian Other
			please elaborate *
Date