For your convenience, forms are available to print and fill out prior to your arrival. Please note, for all children under the age of 18, all consent and financial responsibility forms must be signed by a parent/legal guardian and brought to the appointment if the guardian is not accompanying the child. Forms must be signed by the responsible party, assigning financial responsibility to another party is not permissible.
Before any treatment can be performed on a child under the age of 18, parental/legal guardian consent must be obtained. If you are not able to accompany your child to the appointment, please be sure you are accessible by phone to give consent once a course of treatment is determined. If you will not be available, please send a signed note giving permission for someone else to sign the consent forms. If treatment has been determined in advance, a consent form may be signed prior to beginning.
In addition to completed forms, please bring your current insurance card or copy of your plan booklet to your appointment. Many insurance companies now have changed from using Social Security numbers to a plan specific identification number. Without this information we may not be able to access the benefits of your particular insurance plan. Although we will make every attempt to obtain information regarding your insurance, if we are unable to access your benefits you may be responsible for payment in full for services. If benefit information is received in the future we will be happy to file your claim for you for reimbursement.
Insurance Billing Consent Form
Financial Responsibility Form