I assume financial responsibility for all dental treatment and medications provided for my child. I understand that payment is expected on the date services are provided. Although our office will gladly e-file dental insurance claims as a courtesy to you, any and all account balances are ultimately your responsibility. Insurance plans can vary greatly and some companies arbitrarily select certain services that they will not cover. Please contact us if you make any changes to your dental coverage, so that we may keep accurate and current records of your account. Sixty days is the most we can wait for your insurance company to pay your account balances. After this time, we will need you to pay any remaining balances. We will gladly refund you for any over-payments that occur after you have paid your bill. The parent or guardian who brings the child is responsible for payment, regardless of what a divorce decree may state. Reimbursements must be made amongst the divorced parties and cannot involve the office.


I acknowledge that I have received a copy of this Mountain View Pediatric Dentistry’s HIPAA Notice of Privacy Practices.


I acknowledge that the policy of Mountain View Pediatric Dentistry is for a legally responsible parent or guardian to be present for all dental appointments. If someone other than the parent or legal guardian accompanies your child to their visit we reserve the right to reschedule the appointment. If advance notice is given (at least 48 hours) and we can obtain the necessary paperwork prior to the scheduled visit, we may accommodate your needs on a case by case basis. Certain types of treatment visits (including sedation) always require a parent or legal guardian to be present for the entirety of the visit. Please see additional information on our policies in the additional forms section. CANCELLATIONS AND NO-SHOWS In order to be respectful of other patients’ needs, please be courteous and call our office promptly if you are unable to make your appointment. This will allow us to offer your reserved appointment to a patient in urgent need of treatment and promptly reschedule your child for another appointment date. Any appointment(s) not cancelled at least 24 hours in advance is subject to a $50 cancellation fee. We cannot reschedule your appointment until the fee is paid. Continued cancellations and no-shows can result in dismissal from the practice.


I attest that the information I have provided on this form is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status.

I understand that by signing below I authorize the following procedures to be performed as deemed necessary by the dentist and have read and understand the possible risks and complications of each procedure.

X-Rays & Examination
I understand that my child will be receiving a dental examination from a state licensed and board-certified pediatric dentist. I understand that x-rays may be taken of my child’s teeth as part of the necessary requirements to complete a thorough and comprehensive examination.

Medical Photography Consent
I consent to digital photographs and x-ray images of my child to be used exclusively within their medical record for the purposes of identification and dental treatment.

Dental Cleaning and Fluoride Treatment
I authorize Dr. Hatch and/or his staff members to clean my child’s teeth today. I understand that the application of fluoride is part of the standard of care for children and helps prevents cavities.

Drugs and Medication
I understand that antibiotics, analgesics and topical compounds can cause allergic reactions even with no prior known history. Allergic reactions can cause redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock. I have informed the dentist, to the best of my knowledge, of any adverse reactions my child has had.

I understand that all of the above treatments are the standard of care in pediatric dentistry. It is my responsibility to inform the staff during the registration process if I choose to decline any of the above treatments.

I consent to having my child's photo taken and displayed in the office as part of contests or bulletin boards
I consent to having my child's photo taken and posted as part of online social media including, but not limited to: the office website and blog; Facebook and Yelp

Authorization and Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or exam rendered to my child during the period of such dental care to third party payors, health practitioners and as required by law.