All patients under the age of 18 must be accompanied by a parent or legal guardian at the time of the treatment unless written treatment consent and pre-approved payment has been previously received.

I understand that the information on the health history form will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my child’s medical status.

I agree to inform the office of any changes in address, phone, insurance, etc. that occurs during the course of treatment for my child. It is also my responsibility to notify the office of any changes to my insurance benefits.

I request and authorize Dr. Govindaiah at Springfield Pediatric Dentistry to examine, clean and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental x-rays as it may be considered necessary to diagnose and/or treat my child’s dental problem.

I will allow photographs to be taken of my child’s teeth for diagnostic or educational purposes. I have been informed that my child's identity will be protected at all times.

I understand that dental treatment in children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Springfield Pediatric Dentistry will provide an environment to help children learn to cooperate during treatment using tell-show-do, positive reinforcement and at times voice modulation.

I understand that during treatment, it may be necessary to change or add procedures due to conditions found while working on my child’s teeth. I give my permission to make these changes as necessary.

I authorize Springfield Pediatric Dentistry to communicate with pharmacists, other dental specialists and physicians as necessary by letter, phone or fax.