319-626-5437 | 2761 Oakdale Blvd Suite 4, Coralville, IA 52241
FAQ for Parents
If yes, please specify:
If yes, when?
If yes, briefly explain:
If yes, please list:
If yes, date of removal?
I acknowledge that I am aware of the Provider’s Notice of Privacy Practices posted at the
children’s dental center. The Notice of Privacy Practices describes how identifiable health
information may be used and disclosed and states my rights with respect to my medical information.
I understand that the children’s dental center has the right to revise these information
practices and to amend the Notice of Privacy Practices. I understand that in the event the Notice is
revised, the revision will be posted at the children’s dental center. Upon request, I
may obtain a copy of the Privacy Practices Policy.
I can be reached by the following means to discuss issues related to my child(ren’s) dental records,
dental appointments, insurance policy and billing:
I hereby give permission for the release of any or all medical and dental information to the
person(s) listed below:
The Children’s Dental Center has my permission to use my child(ren’s) photograph publicly to promote the
office. I understand that the images may be used in print in office, or on The Children’s Dental Center
website and social media accounts. I also understand that no compensation shall become payable to me by
reason of such use.
Due to increasing changes with insurance benefits, and in effort to maintain communication as our
practice grows, we wish to inform you of our financial policy.
Please note it is the responsibility of our patients to check with the family’s insurance
carrier for benefit coverage and to understand their dental insurance policy. If, for any reason, the estimated amount is not paid by your insurance company, it becomes your obligation.
the children’s dental center values your time and will do our best to accommodate you
and your family’s work/home/school schedules. We use many different methods of appointment confirmation
from postcards, phone calls, emails, and text messaging to remind you of your appointment(s) with us. If
you cancel an appointment, we ask for a 48-hour notice. If you are unable to give us a two-day notice,
we ask that you call as soon as possible to cancel/reschedule your appointment.
Please note: we are unable to cancel or reschedule
appointments via email or text.An answering machine is available to take your
cancellation after hours.
the children’s dental center reserves the right to charge for any failed or missed
appointments when patients do not show for their scheduled appointment with no attempt to call our
office to cancel or reschedule prior to set appointment.
If multiple appointments are missed in a twelve-month period or a pattern of consistent rescheduling
occurs, we may ask the patient to seek dental care elsewhere.
I have read and understand the above policies. I agree to be responsible for the balance due on my
family’s account. I also understand The Children’s Dental Center reserves the right to charge for