Fishers Pediatric Dentistry Logo

Welcome to Fishers Pediatric Dentistry

Thank you for choosing Fishers Pediatric Dentistry for your child's dental care!

Patient Information

Please enter the patient’s full name.
Please select a date of birth.
Please choose a gender.
Please enter the street address.
Please enter the city.
Please enter the state.
Please enter the zip code.

Primary number and email for communication:

Please enter a phone number.
Please enter an email address.

A parent/legal guardian is REQUIRED to be present at the first appointment.

Please select a relation.


Parent / Guardian Information

Guardian I
Guardian II
Who does the patient live with? (check all that apply)

Dental Insurance Information


Please select whether you have dental insurance.
Primary Coverage
Please enter the insured’s name.
Please enter a date of birth.
Please upload an insurance card.

Please select whether you have secondary insurance.
Secondary Coverage
Please enter the insured’s name.
Please enter a date of birth.
Please upload an insurance card.

Dental History

Dental Concerns

Please select Yes or No.
Please choose a reason.

Please select Yes or No.
Dental Habits
Does your child currently… (check all that apply)
Oral Hygiene & Diet
Does your child currently…








Medical History


Please select Yes or No.

Please select Yes or No.

Please select Yes or No.
Has your child been diagnosed and/or treated for any of the following? (check all that apply)
Allergies (check all that apply)

Consent & Authorization

I give consent to Fishers Pediatric Dentistry to provide necessary treatment to the patient(s) listed above. I affirm that the above information is correct to the best of my knowledge, and it is my responsibility to inform any change in the patient's medical status. I understand that Fishers Pediatric Dentistry may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of all information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand the office operates on a 15-day billing cycle & account balances are due when the statement is issued; otherwise considered past due if not paid by the date printed on the statement. I am responsible for the full balance of the account regardless of my dental benefits, and directly assign Fishers Pediatric Dentistry all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. My signature represents my agreement to all of the terms mentioned above.

FINANCIAL POLICY

Our office is committed to providing you with the highest quality dental care using only the best material and technology available. Our Clinical and Business Teams work closely together to provide a positive environment for visits to our office and assistance with financial requirements. A member of our Business Team will be delighted to discuss our options with you!

Payment Due: The full balance of treatment is due at the time services are rendered. For your convenience we accept cash, check, debit card, CareCredit®, Visa, Master Card, Discover and American Express. Payments can be made in office, by phone, online or mailed.

Financial Responsibility: The parent or guardian bringing the child to our office and authorizing treatment is legally responsible for payment of all charges. We cannot send statements to other persons.

Statements: If you have a balance on your account, we will send you a statement in the mail. It will show your previous balance, any new charges, and any payments or credits applied to your account. We are on a 15-day billing cycle.

Past Due Accounts: Unless prior arrangements have been approved in writing by our office, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the due date printed on the statement. A $10-$25 late fee may be charged on any account that is not paid within fifteen (15) days of the statement date. If necessary, accounts that are not paid may be referred to a collection agency. All reasonable expenses incurred in the collection process will be the account holder’s responsibility.

Insurance: We are happy to file dental claims for our families who have dental insurance! In general, we will file claims to any company that will pay us directly and does not restrict coverage to a list of participating providers. Filing your insurance is not a guarantee of payment. Please understand that the parent or guardian has the final responsibility for payment of any services rendered. Our doctors recommend treatment based on your child’s needs, not on what insurance will pay. Therefore, we will do everything possible to maximize your benefits.

Your complete insurance information/card must be presented at the time services are provided and updated as necessary. In the event that your insurance has not paid your account within 60 days, the balance may be transferred to your account. We reserve the right to discontinue or refuse to file a claim.

We are a participating provider with the following companies: Aetna PPO, Anthem Dental Blue (100,200,300), Anthem Dental Complete, Children’s Special Health Care Services, Delta Dental PPO, Delta Dental Premier, Guardian PPO, and Indiana’s Medicaid and Hoosier Healthwise.

Federal Employees: Insurance plans for federal employees make payments directly to the member. Payment in full will be collected on the day that treatment is provided.

Required Payments: At treatment visits, we collect a percentage of the total cost of treatment, determined by an ESTIMATION of what your insurance will cover, plus any deductible required by your insurance. In the event of underpayment, we will send you a statement in the mail. In the event of overpayment on your part, you will be reimbursed by check in the mail.

Divorce/Separation: The party responsible for the account prior to the divorce or separation remains responsible for the account. After the divorce or separation, the parent or guardian bringing the child and authorizing treatment will be the person responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from them. We will provide you additional copies of receipts if needed.

Returned Checks: There is a $30.00 fee for any checks returned by the bank.

CareCredit®: A convenient alternative to credit cards, cash or checks, CareCredit® is a health care card that is exclusively utilized for dental and medical services. They offer flexible payment options that fit your timetable and budget. For additional information, contact us or visit www.carecredit.com.

Initial:

APPOINTMENT POLICY

We reserve a specific time for your child according to their dental needs and level of cooperation. Young children tend to do better in the dental office when they are not tired. Therefore, we encourage morning appointments, especially for pre-school or nervous children. For many children, just a simple filling at the end of the day, when they are tired, can seem like a major ordeal. After-school appointments are limited and in high demand. We understand school policies can often make it a challenge when scheduling appointments. Dental appointments ARE excused absences, and we will gladly provide a school excuse for your child.

We value your time as much as we hope you value ours and will make every effort to see your child at the time scheduled. We appreciate your promptness in arriving on time for your child’s visit. If you are more than 10 minutes late, it may be necessary to reschedule your child’s visit. We do ask that you please remember some children may require more patience and “TLC” than others, causing a slight delay. We ask for your patience and to keep in mind that your child may be the next little one needing our attention.

Appointment Changes: We understand that unforeseen emergencies do occur. If you are unable to keep a scheduled appointment, a 48-hour notice is required. We reserve the right to charge your account a $25.00 fee for repeated last-minute cancellations or broken appointments.

Appointment Confirmations: Any appointment that is not confirmed within 24 hours of the appointment time will be cancelled so that we may offer that time to another child. A failed appointment may result in a $25.00 no-show fee and/or dismissal from the practice.

I have read the above policies and understand my obligations with Fishers Pediatric Dentistry for my child's dental care. I understand that I am financially responsible for any service that my dental insurance plan does not cover. I affirm that my signature represents my agreement to all of the terms mentioned above. Once you have signed this policy, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

Patient Authorization for Use and Disclosure of Protected Health Information: I authorize Fishers Pediatric Dentistry to release any information…