Pediatric Dental Specialists - Patient Update

X-rays may be taken as part of today’s dental examination. I UNDERSTAND that the doctor’s recommendation for x-rays is based on my child’s individual needs and NOT on what the insurance company determines they will cover. I assume financial responsibility for the cost of x-rays should my insurance company deny payment.
****If there is any reason why your child should not have x-rays taken today, please notify us.****
Medical Update


Family Record Update


INSURANCE INFORMATION


I hereby authorize the release of any information including the diagnosis and the records of any treatments or examinations rendered to my insurance company(s).This release is solely for the purpose of facilitating the billing and reimbursement directly to the doctor, of insurance benefits under which I am entitled.

Pediatric Dental Specialists
Santos Cortez, D.D.S., Inc. – Ana M. Planells, D.D.S. – Estela Sanchez, D.D.S.
3320 Los Coyotes Diagonal - Suite 200 - Long Beach, CA 90808 – (562) 377-1375 – Fax (562) 377-1343