Existing Patient Update Colwick Pediatric Dentistry

Has your Dental Insurance changed:

YesNo

Have you had any of the following symptoms or events within the past 21 days? Please check all that apply:

Has your child been hospitalized or evaluated in the ER since last visit:

YesNo

Is there additional medical information we should know?

YesNo

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary services my child may need. The parent or guardian who accompanies the child is responsible for the payment at the time of service unless prior arrangements have been approved. I agree to pay any additional charges related to the costs of collection (including, but now limited to, collection agency fees, reasonable attorney fees, and legal costs) in the event that I would fail to pay my bill. I have had the opportunity to ask all questions and understand that I may ask additional questions at any time. I understand that I will be asked to complete the questionnaire at each visit.

Thank You!

We've copied your review, after you click 'Publish' please paste your review by selecting 'ctrl' + 'v' into the review comments section.

Publish to Social

Fill Up Form

Existing Patient Update