Greetings,

Thank you for entrusting Fishers Pediatric Dentistry with your child’s smile.  To expedite your experience when you first arrive, we prepared the following FOUR forms to fill out online:

 
1. New Patient Information
2. Office Policies
3. Acknowledgement of Privacy Practices
4. Consent for Fluoride Treatment
 
Upon completion of each form, you will be prompted to fill out the next.  Please be sure to notify us of any changes when you arrive. 
 
We are excited to meet you and your family!
 
“One of life’s greatest pleasures… is a child’s smile!”

 
PATIENT INFORMATION
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Who is accompanying the child today or is expected to on the date of their appointment?

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PARENT INFORMATION
   
GUARDIAN (I)
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GUARDIAN (II)
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
DENTAL INSURANCE INFORMATION
   
PRIMARY COVERAGE
   
SECONDARY COVERAGE
   
REFERRAL INFORMATION

Please share with us how you heard about our office…

 
 
 
 
 
 
 
 
 
 
DENTAL HISTORY

DENTAL CONCERNS


 

(If Yes)

DENTAL HABITS

Does your child currently… (check all that apply)

HYGIENE ROUTINE

(check all that apply)

MEDICAL HISTORY
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I affirm that the above information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the patient's medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I understand that Fishers Pediatric Dentistry may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of all information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand that I am responsible for the full balance of the account regardless of my dental benefits and directly assign Fishers Pediatric Dentistry all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. I affirm that my signature represents my agreement to all of the terms mentioned above.

 

*Guardian Signature:

FINANCIAL POLICY
Our office is committed to providing you with the highest quality dental care using only the best material and technology available. Our Clinical and Business Teams work closely together to provide a positive environment for visits to our office and assistance with financial requirements. A member of our Business Team will be delighted to discuss our options with you!

Payment Due: The full balance of treatment is due at the time services are rendered. For your convenience we accept cash, check, debit card, CareCredit®, Visa, Master Card, Discover and American Express. Payments can be made in office, by phone, online or mailed.
 

Financial Responsibility: The parent or guardian bringing the child to our office and authorizing treatment is legally responsible for payment of all charges. We cannot send statements to other persons.
 

Statements: If you have a balance on your account, we will send you a statement in the mail. It will show your previous balance, any new charges, and any payments or credits applied to your account. We are on a 15-day billing cycle.
 

Past Due Accounts: Unless prior arrangements have been approved in writing by our office, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the due date printed on the statement. A $10.00 late fee may be charged on any account that is not paid within fifteen (15) days of the statement date. If necessary, accounts that are not paid may be referred to a collection agency. All reasonable expenses incurred in the collection process will be the account holder’s responsibility.
 

Insurance: We are happy to file dental claims for our families who have dental insurance! In general, we will file claims to any company that will pay us directly and does not restrict coverage to a list of participating providers. Filing your insurance is not a guarantee of payment. Please understand that the parent or guardian has the final responsibility for payment of any services rendered. Our doctors recommend treatment based on your child’s needs, not on what insurance will pay. Therefore, we will do everything possible to maximize your benefits.

Your complete insurance information/card must be presented at the time services are provided and updated as necessary.

In the event that your insurance has not paid your account within 60 days, the balance may be transferred to your account. We reserve the right to discontinue or refuse to file a claim.

We are a participating provider with the following companies:Aetna PPO, Anthem Dental Blue (100,200, 300), Anthem Dental Complete, Children's Special Health Care Services, Cigna PPO, Delta Dental PPO, Delta Dental Premier, Guardian PPO, Health Resources Inc., and Indiana's Medicaid and Hoosier Healthwise.  

Federal Employees: Insurance plans for federal employees make payments directly to the member. Payment in full will be collected on the day that treatment is provided.
 

Required Payments: At treatment visits, we collect a percentage of the total cost of treatment, determined by an ESTIMATION of what your insurance will cover, plus any deductible required by your insurance. In the event of underpayment, we will send you a statement in the mail. In the event of overpayment on your part, you will be reimbursed by check in the mail.
 

Divorce/Separation: The party responsible for the account prior to the divorce or separation remains responsible for the account. After the divorce or separation, the parent or guardian bringing the child and authorizing treatment will be the person responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from them. We will provide you additional copies of receipts if needed.
 

Returned Checks: There is a $30.00 fee for any checks returned by the bank.
 

CareCredit®: A convenient alternative to credit cards, cash or checks, CareCredit® is a health care card that is exclusively utilized for dental and medical services. They offer flexible payment options that fit your timetable and budget. For additional information, contact us or visit www.carecredit.com.
    

 

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APPOINTMENT POLICY
Children tend to do better in the dental office when they are not tired. Therefore, we encourage morning appointments, especially for pre-school or nervous children. For many children, just a simple filling at the end of a long day, when they are tired, can seem like a major ordeal. Please keep in mind, one of our goals is providing dentistry that is as pleasant as possible for your child. Also keep in mind that a dental appointment is an excused absence from school.

When we schedule an appointment for your child, that time is reserved solely for your child. We do not double book and we take pride in the fact that because we value your time, as much as we hope you value ours, we make every effort to see your child at the time scheduled. For this reason, it is very important that you have your child in the office at the time scheduled. If you are more than 10 minutes late, it may be necessary to reschedule your child’s visit.

Cancelling or Rescheduling: If you are unable to keep a scheduled appointment, a 48-hour notice is required. We understand that unforeseen emergencies do occur, however, we reserve the right to charge your account a $25.00 fee for repeated last minute cancellations or broken appointments.

Effective Date: Once you have signed this policy, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

 
 

*Initial:


I have read the above policies and understand my obligations with Fishers Pediatric Dentistry for my child’s dental care. I understand that I am financially responsible for any service that my dental insurance plan does not cover. I affirm that my signature represents my agreement to all of the terms mentioned above.
 
  
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*Guardian Signature:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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Below is a list of ways our office may contact you. Please check all that apply. Checking a box will give permission to leave as thorough of a message as needed from our dental office.



Patient Authorization for Use and Disclosure of Protected Health Information
I authorize Fishers Pediatric Dentistry to release any information including diagnosis and the records regarding any treatment or examination rendered to my child during the period of such dental care to third party payers and/or other health practitioners.  In the event of my absence, the following individuals may bring my child/children to and from their appointments along with have access to medical and financial information.
 



I  , have been offered a copy of this office’s Notice of Privacy Practices.
 

*PARENT/GUARDIAN Signature

Consent for Fluoride Treatment
Fluoride is effective in preventing and reversing the early signs of dental caries (tooth decay). Researchers have shown that there are several ways through which fluoride achieves its decay preventive effects. Fluoride incorporates into the tooth structure making it stronger resulting in teeth that are more resistant to acid attacks. Fluoride also acts to repair or remineralize areas in which acid attacks have already begun.

Fluoride application is an important part of your child’s comprehensive preventative program at Fishers Pediatric Dentistry. Fluoride not only helps prevent new decay from developing, it also helps protect existing dental work so that fillings are replaced less frequently, decreases sensitivity, makes teeth last longer and saves you money! Fluoride is most effective when applied after the dental cleaning and all the plaque and build up have been removed from the tooth’s surface.  It is our office protocol to apply fluoride varnish at each routine care appointment for your child to receive maximum benefit.
 
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*Parent/Guardian Signature:

 
9126 Technology Lane, Suite 100, Fishers, IN 46038
P: (317) 598-9898
F: (317) 596-9659
www.fisherspediatric.com