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
Pediatric Dental Specialists may use my cell phone number to call or text regarding appointments, treatment, insurance, and my account. I understand that I can withdraw my consent upon written request.


INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION


FINANCIAL AGREEMENT
All accounts are due and payable at the time services are rendered, unless prior arrangements have been made. The total fee is your personal obligation. However, if you have dental insurance which will cover the services rendered, please be sure you have informed our office. As a courtesy, we will file the necessary insurance claim for payment on your behalf.
We will help expedite your claim so that you receive the correct amount to which you are entitled under the terms of your policy. The difference (if any) between amounts paid by your insurance (where there is an assignment of benefits) and the amount billed is your responsibility.
I have read the above and I understand that I am responsible for all charges incurred.
By signing below, I certify that I have completely read, understand as well as agree to the above statement(s)herein:

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