Patient Registration Form – Children

PATIENT INFORMATION
INSURANCE INFORMATION OF PARENT/GUARDIAN
If the child has secondary coverage:
MEDICAL HISTORY
Have you had an allergic or unusual reaction to any of the following? (Please check mark the boxes below)
Have you ever been treated for any of the following? (Please check mark the boxes below)
Please answer all questions below:
Please answer all questions below:
PLEASE READ THE FOLLOWING CAREFULLY
Office Policy
  • Payment is required after EACH appointment for work done that day.
  • We will gladly complete Dental Insurance Claim Forms with the following understanding:
    a) The parent/guardian is financially responsible for the entire cost of the treatment.
    b) Payment is to be made to “Dental Land Professional Corporation” by the patient/guardian or by direct billing to the insurance company.

iTrans
  • Benefits payable from claims submitted electronically will be assigned to Dental Land and payment will be received by the Dentist directly.
CANCELLATION/ NO SHOW POLICY
  • At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
  • Missed Appointments will incur a firm charge of $50.00
  • All outstanding fees must be paid in full before further appointments will be booked.
  • Should you miss an appointment, it is your responsibility to call and rebook.
  • Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.
Statement of Understanding
I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Dental Land Professional Corporation's policy and understand that breaching it in anyway may result in disciplinary action.
PARENT/ GUARDIAN ACCEPTANCE

THIS IS TO CERTIFY THAT I, THE UNDERSIGNED, CONSENT TO DENTAL AND ORAL SURGERY PROCEDURES WITH THE USE OF LOCAL ANAESTHETIC AND/OR RELATIVE ANALGESIA AS AGREED TO BE NECESSARY OR ADVISED BY THE DENTAL PROFESSIONAL, AND WILL ASSUME RESPONSIBILITY FOR FEES ASSOCIATED WITH THOSE PROCEDURES.

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Contact Information
Medical Condition
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