Name of Minor/Child
First Last Sex Home Address Mailing Address Name of Parent/Guardian
First Last Emergency Contact Name
First Last Check if your referral came from MultiCare Health Systems Consent In my absence, I give permission for the following adult(s) to bring my child to LDCC, make healthcare decisions, and provide consent for treatment. This authorization is good for this calendar year. Name
First Last Name
First Last Name
First Last Dental Insurance Information
LDCC accepts WA Apple Health (Medicaid/Provider One), most private insurances, and offers a sliding fee scale.
Below please indicate which option(s) apply to your child.
Please check and provide information for all that apply.
WA Apple Health (Provider One) Primary Private Insurance Subscriber Name
First Last Address Insurance Company Address Secondary Private Insurance Subscriber Name
First Last Subscriber Address Insurance Company Address Sliding Fee Scale I am interested in applying for Financial Assistance for services provided by LDCC. In order to receive Financial Assistance, a separate financial assistance application must be completed along with providing proof of household income on an annual basis. Dental Benefits Claim Information
We are pleased that many of you have dental benefits and our office will assist you in obtaining the maximum benefits specified in
your contract. Your benefits are a contract between you, your employer and/or a carrier. We will assist you in determining your benefits as best we can. Because plans differ from carrier to carrier and policy to policy, our office many refer you to your carrier or your
employer’s benefits coordinator for assistance in understanding your plan. As a courtesy to you, we will file your benefits claim and
accept assignment of benefits. Not all services are covered benefits in all contracts. Some carriers and employers select only some
services to be covered. You are responsible for payment of all services regardless of the payable benefits.
INSURANCE AND FINANCIAL POLICY I authorize Lindquist Dental Clinic for Children, or my insurance company, to release any information required for payment or review of any dental claims. I am financially responsible to Lindquist Dental Clinic for Children for all balances due and assign my benefits to Lindquist Dental Clinic for Children. My portion of pay and co-pay (the amount your insurance does not cover) or any amount my insurance does not cover, or total amount should I not have insurance, is due at the time of service unless other arrangements are made. I have read and understand this. TREATMENT CONSENT I consent to the diagnostic procedures and treatment(s) deemed necessary to thoroughly diagnose the patient’s dental needs. If the patient is a minor and/or under custodial care, the below responsible party represents that they are legally authorized to obtain medical services for the patient. Name
First Last Policies Acknowledgement Child's Name
First Last Appointment Policies
It is the goal of Lindquist Dental Clinic for Children (LDCC) to provide a positive dental experience for
both the patient and the family. In order to provide the best care possible for all the children we serve,
we must adhere to the following policies:
Parents/Guardians Must Remain in the Clinic:
Parents or Guardians of children with scheduled appointments must remain in the clinic at all times. This is very
important because there are times that the providers may need to speak with you about your child’s care and we will not
be able to proceed if you are not in clinic.
Confirmation or/Cancellation of Appointment:
We have many children in need of appointments at LDCC, it is imperative that appointments be confirmed, either via
the text you receive or by phone. Failure to confirm could result in your child/children being rescheduled for a later
date. If you need to cancel or reschedule your appointment it is imperative that you notify our office by 5 pm the
day before your scheduled appointments.
A late arrival is arriving any time after your scheduled appointment. If you arrive late for your appointment, you may
find that your appointment may have been filled by another patient. You will be offered to wait on a standby basis for
an opening that day or to reschedule your appointment.
Your child’s appointment will be considered a “no show” for that appointment if we are not notified of your need to
cancel the appointment by 5 pm day prior to your child’s appointment OR if you fail to show for your
appointment. Patients with two (2) “no- show appointments within a rolling 12 month period will be ONLY be
seen on standby status.
Scheduling with Multiple Children:
LDCC will schedule up to 3 children on the same day at our Parkland Clinic, as long as there are NO MISSED
appointments. In our Bremerton Clinic, we will schedule 2 children on the same day, again with NO MISSED
appointments. Additional children will be scheduled for another day or may be seen on stand-by schedule as available.
A minimum payment of 25% of the open balance or the family balance is due at time of service, OR you have
current and up to date payment plan. DSHS patients must bring their Provider One card to insure current monthly
eligibility. Private insurance patients must bring proof of insurance and pay their portion at each appointment,
unless on an established and current payment plan.
Your family may qualify for financial assistance for your patient portion. To apply for financial assistance you must
complete the financial assistance form and provide proof of income. The amount of assistance is based on family
size and annual gross income. Financial assistance must be renewed each calendar year.
Parent/Legal Guardian Name
First Last Photo Release Child's Name
First Last Consent I, as parent or legal guardian of the person named above, I authorize Lindquist Dental Clinic for Children (LDCC) to photograph, televise, or otherwise illustrate as deemed advisable for diagnostic, educational, fundraising, marketing, or research purposes and to enhance the medical record. I further authorize the use of such audio-visual material (video tape, audio tape, photographs, motion pictures, and other resulting record(s)) for teaching purpose, to illustrate scientific papers or lectures, marketing or fundraising at any time hereafter without inspection or approval, on my part, of the finished product or the specific use to which this material may be applies. I hereby consent to any or all of the above procedures and understand that the resulting media may be used on television, in print and online. LDCC shall own all rights, titles and interests, including the copyright, in and to the media, including the media and related materials, to be used and disposed of, without limitation, as LDCC shall in LDCC’s sole discretion determine. Parent/Legal Guardian Name
First Last Acknowledgement of Receipt of Notice Child’s Name
First Last Consent I give this practice/clinic my consent to use or disclose my child’s protected health information to carry out their treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have reviewed Lindquist Dental Clinic for Children’s “NOTICE OF PRIVACY PRACTICES” before signing this consent. I understand that Lindquist Dental Clinic for Children has the right to change their privacy practice and that I may obtain any revised notice at Lindquist Dental Clinic for Children. I understand that I have the right to request a restriction of how my child’s protected health information is used. However, I also understand that Lindquist Dental Clinic for Children is not required to agree to the request. If Lindquist Dental Clinic for Children agrees to my request, they must follow the restriction(s) I have submitted in writing. I also understand that I may revoke this consent at any time, by making a request in writing except for information already used or disclosed. Parent/Legal Guardian Name