ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTIVES

** You May Refuse to Sign This Acknowledgement **

I, _________________________________________ have received a copy of My Kids’ Dentists Privacy Practices.

________________________________________ Signature

________________________________________ Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Norice of Privacy Practices, but acknowledgement could not be obtained because:

o Individual refused to sign

o Communication barriers prohibited obtaining the acknowledgement

o An emergency situation prevented us from obtaining acknowledgement

o Other (Please specify)

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My Kids’ Dentists

Consent of Health Information

Because patient confidentiality is a primary care at My Kids’ Dentists, it is important that you provide us with the following to ensure that there is no violation of your privacy. In the event that you cannot be reached, My Kids’ Dentists may leave a message regarding confirming appointments, treatment, or account balances with the following: Name: _____________________________________________

Phone Number: ______________________________________

E-mail: _____________________________________________

Other (Specify):______________________________________

In the event that I, _______________________ cannot accompany my child to the dental visit I give consent that __________________________________, _________________________________, _______________________________, or _________________________________ can bring them to their dental appointment. I understand that if any of the above information changes, it is my responsibility to notify the staff of My Kids’ Dentists. _____________________________________ ____________________ Parent/Guardian’s Signature Date

My Kids’ Dentists

Consent for Treatment

Please read this form carefully. If you do not understand something to your satisfaction, please ask questions as we are happy to explain it.

I request and authorize My Kids’ Dentists to examine, clean and provide any necessary dental treatment for: __________________________________________ _________________________________ Patient’s Name Date

1. I authorize the use of digital dental X-rays as may be considered necessary to diagnose and/or treat my child’s dental needs. I further authorize the use of anesthetics as may be considered necessary to treat the dental problem (s). I understand that Nitrous Oxide (laughing gas) is an elective procedure and is not required to provide the necessity treatment. I understand there are possible compilations/risks associated with Nitrous Oxide that may include, but are not limited to a tingling sensation or a feeling of heaviness, laughter or giddiness, a floating sensation or a feeling of nausea, vomiting or agitation.

2. I understand that during the course of the patient’s dental treatment , something unexpected may arise that may necessitate procedures in addition to or different from those listed on the Treatment Plan and that I will be consulted prior to initiation or treatment procedures not listed. I am aware that the practice of dentistry is not an exact science and acknowledges that no guarantees have been made to me concerning the results of the dental treatment that the patient receives at My Kids’ Dentists.

3. I understand that dental treatment for children includes efforts to guide their behavior by helping by helping them understand the treatment in terms appropriate to their age. We will provide an environment likely to help children learn to cooperate during treatment using a variety of techniques including praise, explanation and demonstration of procedures and instruments, and variable voice control and loudness.

4. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided. During such disruptive behavior, it may be necessary for the assistant to hold the patient’s hands, stabilize the head and/or control leg movements. I further understand that should the patient become combative or uncooperative during dental procedures with excessive body movements, the patient may need to be wrapped in a “hug blanket” or “papoose board” to prevent injury and enable the Dentist to safely provide the necessary treatment.

5. I understand that that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent and procedures have already been performed or initiated.

______________________________________________ _______________________ Print Name of Person Consenting to Treatment Date ______________________________________________ Signature of Person Consenting to Treatment ___________________________________________________ __________________________ Signature of Witness Date

My Kids’ Dentists 205 Hawkins Store Rd NW, Suite 100 Kennesaw, GA 30144 PHONE (770)926-3400 FAX (770)926-6317

Financial Policy

Thank you for choosing our office for your child’s dental treatment. We are committed to their

successful treatment. Please understand that payment of your bill is considered a part of your child’s

treatment.

x Please be aware that the parent bringing the child to My Kids’ Dentists is legally responsible for payment of charges. We cannot send statements to other persons.

x Payment is expected in full for each appointment as services are rendered. For your convenience we accept cash, VISA, MasterCard, American Express and Discover. We also offer patient financing through CareCredit .

x Dental Insurance: We accept most insurance plans and are in network with Cigna PPO, Humana PPO and United Concordia. Please be aware there is no direct relationship between our office and your insurance company. The plan chosen by you, and/or your employer determines your insurance benefits. As such, we have no say in selection of your insurance company, no control over the terms of your contract, the methods of reimbursement or the determination of your insurance benefits. We will accept assignment of benefits from your insurance company; however you are responsible for the full balance including any amount that is not paid by your insurance company.

x We will file your claim electronically as a courtesy, but if the insurance company will not pay us directly, you are responsible for the entire balance and the insurance company will send the payments to you.

x If you break/miss an appointment without a twenty four (24) hour notice, we reserve the right to charge a $50 broken appointment fee.

x Appliances: The cost of the appliance must be paid on the day your child’s impressions are taken. This is necessary because we must pay the lab bill when the appliance is ordered, not when they are delivered.

My Kids’ Dentists requires that all outstanding balances be paid in full within thirty (30) days unless other arrangements have been made. If we have not received payment or you have not contacted us within thirty (30) days, further action may be taken with a collection agency or with Small Claims Court.

We reserve the right to apply a fee of $5.00 a month from the date of service, as well as a $30.00 collection fee if a collection agency is necessary.

SIGNATURE_____________________________________ DATE___________________________

WITNESS _______________________________________ DATE___________________________