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Have there been any changes to your dental insurance coverage since your child’s last visit to our office?

Please be advised that if you do not inform us of changes to your dental insurance, we cannot guarantee that covered services will be paid in a timely manner. As a result, you may be responsible for paying all outstanding balances and seeking a reimbursement from your insurance company.

I understand the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff of Pediatric Dentistry of Brandon PA to perform the necessary dental services my child may need. I understand that I am responsible for the cost of these dental services at the time of the visit, unless prior arrangements have been made.