"*" indicates required fields
PRIVATE PAY PACKET
FINANCE POLICY AGREEMENT
The CarePoint Dental Anesthesia Group of Michigan, herein after known as “CarePoint”, is dedicated to providing specialized anesthesia services to the familiar and comfortable environment of your dentist’s office, bringing a tailored and personal touch to your child’s care. We would like to advise you of your financial obligations. Please check below that you have read, understood, and acknowledge this Finance Policy Agreement.
I, the undersigned, certify that I have read, understood, and acknowledge that I have retained a copy of this Finance Policy Agreement. I also understand and acknowledge my financial responsibility for the dental anesthesia services provided by CarePoint Dental Anesthesia Group of Michigan. By signing below, I authorize CarePoint to submit payment for any remaining balanace due on or after the date of service. I can alternately provide my card information through CarePoint's website in the form of a payment.
Credit Card Payment Authorization
NEW PATIENT INTAKE FORM(Private Pays or Self-Pays)
PARENT OR LEGAL GUARDIAN INFORMATION
PREGNANCY / NEONATAL HISTORY
INFANCY / CHILDHOOD / ADOLESCENCE HISTORY
Other Medical Conditions:
** PRE-OPERATIVE GUIDELINES **
** IMPORTANT NOTIFICATION **
A Parent or a Legal Guardian must be present and remain at the dental office during the time of service.
HIPAA AND OUR PRIVACY POLICIES
(The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) addresses the manner in which a Patient’s individual health information may be used or disclosed by Covered Entities (as defined in HIPAA) and other individuals and entities, such as a Provider. For more information regarding your rights under HIPAA, please visit their site at https://hhs.gov/ocr/privacy.)
Please check below that you have read, understood, and acknowledge the following:
I, the undersigned, certify that I have read the above pre-operative guidelines and that the above information is complete and accurate to the best of my knowledge. I understand that providing incomplete or inaccurate information may negatively influence my child’s treatment and treatment results.
CONSENT FOR DENTAL ANESTHESIA SERVICES
The following is provided to inform patients about having treatment under dental anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatments.
I, the undersigned, hereby authorize and request any doctor represented with CarePoint Dental Anesthesia to administer anesthesia to my child as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for my child’s well-being may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:
I, the undersigned, consent to the anesthesia deemed appropriate by my child’s anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives, and expected results of the anesthetic plan of care.