Please read the above and understand that the information provided in this form is true and accurate. A truthful health history will help ensure the best possible dental treatment. The information provided here will be used by the doctor and patient to inform any further discussion of the patient’s health prior to or during an appointment. By signing below, you also acknowledge that you will not hold the dentist the dental practice or any other member of the practice staff responsible for any action or lack of action because of errors or omissions that may have been made during the completion of this form.
I give permission to the person(s) listed below to accompany my child to the office of Santa Barbara Children's Dentistry for dental appointments. I also give permission to the person(s) listed below to make any necessary decisions regarding dental treatment for my child, including but not limited to:
I understand this consent will be valid for one year or until I rescind this agreement in writing.
Please read this form carefully. If you do not understand any portion of this document, please alert our staff and we would be more than happy to explain further. By signing this document, I request and authorize the following dental treatment for my child by Dr. Hayley Cox and staff.
Our goal is to provide treatment in a timely manner with as few visits as necessary. In order to provide the best services to our patients, we require at least a 48-hour notice of cancellation or change to your child's appointment. We understand that unforeseen circumstances may arise and will make every effort on our end to be as accommodating as possible. A $50 fee may be assessed for multiple missed appointments, short notice, or cancelled appointments. Multiple failed appointments may result in dismissal from our office.
You will receive two letters for missed appointments without proper notification given. After the second letter, you will be placed on a "same-day appointment" list. On a day that you feel it is convenient to bring your child in, call our office and, if time allows, we will place them in our schedule.
Parents/patients that are running late are asked to call the office as soon as possible to check with the front office team to determine if the office will still be able to keep their appointment. Cancellations left on our voicemail are not accepted and will not be considered cancelled. Please call during regular business hours and speak with a team member if you need to make a change.
In consideration of other patients, your child's appointment may be rescheduled if you are more than 10 minutes late for your scheduled appointment time.
School holidays, as well as before and after school hours are our most popular appointment times. Appointments canceled with less than 2 business days' notice that are scheduled on a school holiday, before or after school time will not be rescheduled on another school holiday, before or after school appointment time.
We greatly appreciate your cooperation in helping us provide excellent care to your family. Please sign below that you have read and acknowledge the above information provided to you.
We are pleased to welcome you to our practice. Our desire is to provide your child with the highest quality dental care in a caring and enjoyable atmosphere. It is our policy to make definitive financial arrangements with you before any treatment begins. Below is an explanation of our payment procedures. If you have any questions, please do not hesitate to ask.
I have read, understand, and accept the above financial agreement and agree to the terms set forth regarding payment.
I hereby authorize Santa Barbara Children's Dentistry or any of their assignees to take photographs, slides, and/or videos of my child. I understand the photographs, slides, and videos will be used as a record of my child's care, may be used for communication with other health care professionals, and advertising purposes (social media and/or marketing). I further understand that if the photographs, slides, and videos are used in any publication or as a part of a demonstration, my child's identifying information (first name only) may be used unless stated differently below. I understand that information disclosed under this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. By signing this Agreement, I waive the right to inspect or approve the finished product. I do not expect compensation, financial or otherwise, for the use of these photographs, slides or videos, and waive any right to royalties or other compensation arising or related to the use of the photograph, slides, or video.
If I wish to revoke this consent, I may do so in writing.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate and determine our compliance with the requirements of Section 164.500
Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization at any time in writing except to the extent that your dentist or the dental practice has acted in reliance on the use or disclosure indicated in the authorization.
Following is a statement of your rights with respect to your protected health information.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against your for filing a complaint.
This notice was published and becomes effective on/or before June 1, 2020
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at (805) 421-4469
Your signature below is only abacknowledgement that you have received this Notice of our Privacy Practices.
Dr. Hayley Cox
3740 State Street
Santa Barbara, CA 93105