Board Certified Pediatric Dentist

Francisco J. Rodriguez, DDS, MS

2185 Brinker Road Suite 110

Denton, Texas. 76208

Phone: (940) 222-4580 Fax: (940) 222-4590

Parent / Guardian Information:

□ Mother □ Stepmother □ Grandmother □ Guardian □ Other ______

Name:______DOB:______

LastFirstMiddle Initial

Address:______

Street address / RR / Box #CityStateZip Code

Driver’s License #______SSN: ______

Home Phone:______Cell Phone:______

Employer: ______Work Phone: ______

Email Address: ______Ok to contact via email? □ YES □ NO

□ Father □ Stepfather □ Grandfather □ Guardian □ Other ______

Name:______DOB:______

LastFirstMiddle Initial

Address:______

Street address / RR / Box #CityStateZip Code

Driver’s License #______SSN: ______

Home Phone:______Cell Phone:______

Employer: ______Work Phone: ______

Email Address: ______Ok to contact via email? □ YES □ NO

Acknowledgement of Receipt of Notice of Privacy Practices

(You may refuse to sign this acknowledgement)

I have read and understand the above statement and a copy of this office’s Notice of Privacy Practices has been made available to me.

______

SignatureDate

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Printed Name

˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚

For office use only:

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

□ Communication barriers prevented obtaining the acknowledgement

□ An emergency situation prevented us from obtaining acknowledgement

□ Individual refused to sign

□ Other ______

Pediatric Dentistry of Denton ~ 2185 Brinker Rd. Suite 110 ~ Denton, TX 76208 ~ (940) 222-4589

◊◊◊ PARENTAL AUTHORIZATION, RESPONSIBILITY AND AGREEMENT ◊◊◊

◊ AUTHORIZATION FOR DENTAL EXAMINATION & TREATMENT OF A MINOR ◊

Please list all children that we treat:Name:______DOB:______

Name:______DOB:______Name: ______DOB:______

Who else do you authorize to bring your children for treatment?

Name:______Relation: ______Phone:______

I am a parent/guardian of the above named minor child(ren). I do hereby authorize and consent to any x-rays, examinations, anesthetic, sedative, or dental treatment rendered under the general, direct, or indirect supervision of Dr. Francisco J. Rodríguez, DDS, MS, staff members, or agents, as he may deem necessary. I authorize the dental staff at Pediatric Dentistry of Denton, P.A. to perform any and all treatments for my above named child(ren) and consent to such methods, drugs, and agents as may be indicated in connection with his or her dental care.

◊ FINANCIAL RESPONSIBILITY ◊

Subscriber Name:______DOB:______

Subscriber Employer:______SSN: ______

Insurance Carrier:______Insurance #: ______

Member ID:______Group #:______

□ Private Pay □ Medicaid: (circle one) MCNA │ DentaQuest │ Sooner Care

I assume financial responsibility for all dental treatment and medications provided for my child(ren), and understand that payment is expected on the date services are provided. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions and authorize direct payment to Pediatric Dentistry of Denton, P.A. for dental benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and I therefore am ultimately responsible for payment of services rendered.

◊ CANCELLATION POLICY ◊

In order to serve our patients better, we have instituted a cancellation policy. If you cannot make it to your appointment please contact us 24 hours in advance to cancel or reschedule. Your appointment will also be considered “missed” if you are 10 or more minutes late. It is our policy that patient will be marked as inactive if he or she misses more than one appointment.

◊ ACKNOWLEDGEMENT ◊

I have read, understand, and agree to abide by all of the above statements. Furthermore, I affirm that the information contained in these forms is correct and I understand that providing incorrect information can be dangerous to my child’s health. I understand that it is my responsibility, and I hereby agree, to inform this dental office of any changes in my child’s health status, insurance information and/or contact information. Finally, all authorizations contained herein will remain in effect until cancelled by me in writing.

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SignatureDate

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Printed Name

Pediatric Dentistry of Denton

Specialized care for infants, children, children with special needs, and adolescents