Dental habits and history (check yes or no)

Has child had or does child currently have any of the following?

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform this office if my minor child ever has a change in health. I am the parent, guardian, or personal representative of the child named above, and there are no court orders in effect that prohibit me from signing this consent. I hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance and assign directly to Eastgate Family Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my minor child's health care information and may disclose such information to the insurance company(ies) for the purpose of obtaining payment for services. This consent will end when the current treatment plan is completed or one year from the date signed below.