"*" indicates required fields
Thank you for choosing our office for your child’s dental care needs. We are committed to providing exceptional dental care and helping your child achieve ultimate oral health.
**All estimated fees are due 1 week prior to the scheduled surgery date**(You may request to make this payment by phone or through text)
We will gladly verify your dental benefits and process your insurance claims with the following agreement:
A copy of the treatment plan has been provided. The proposed treatment plan is made based on a clinical examination and any x-rays that we were able to obtain. Depending on the temperament of the child we may not have been able to obtain optimal x-rays or complete a thorough examination in the office. Once the child is under general anesthesia the doctor will complete a thorough examination and obtain any further x-rays that are needed. Consequently, the final treatment may vary from the proposed treatment.