ROBERT HARRISON, D.M.D., M.S.D. 700 McCarthy Boulevard, New Bern, NC 28562 252-633-0424 • Fax: 252-638-6662 info@coastalpediatricdentistry.com www.drbobh.com
To assist us in keeping your child's medical history up to date, would you please answer the following questions:
In order to continue to provide the best possible care to your children, would you please offer your comments below:
Because your child is a minor, it becomes necessary that a signed permission is obtained from a parent or guardian before any dental services can be rendered.Authorization is hereby granted for dental treatment. I will be responsible for any bill incurred on this child for dental treatment.In an effort to reduce our billing costs so that we can keep your fees down, we require that all fees or estimated co-payments be made on the day of the appointment.
AS OF AGE 15, MOST PATIENTS WILL BE REFERRED TO A GENERAL DENTIST
INSURANCE AUTHORIZATION AND ASSIGNMENT I hereby authorize Dr. Robert Harrison D.M.D., M.S.D. to furnish information to insurance carriers concerning my dependent's treatments and I hereby assign to the dentist all payments for his services rendered to my dependents. I understand that I am responsible for any amount not covered by insurance.
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