Credit Card Authorization

Name (As it appear on card)* Credit Card #* Exp date:* CVV code:* Zip Code* Email address* Signature Δ

New patient forms

New Patient InformationDate* MM slash DD slash YYYY Patient Name* First Last Nickname Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code WeightIn poundsHeightIn inchesSex DOB* MM slash DD slash YYYY AgePlease enter a number less than or equal to 99.Patient Name First Last Nickname WeightIn poundsHeightIn inchesSex [...]

X-Ray radiographs refusal form

Fishman Pediatric Dentistry 552 Jacksonville Dr. Jacksonville Beach, FL 32250 (904)247-4097 This form is so that I may fully understand what is recommended for my child and the risks associated with refusing dental radiographs (x-rays). The American Dental Association’s and the Food and Drug Administration’s current guidelines prescribing dental radiographs (x-rays) are as follows: Routine [...]

X-Ray and Fluoride Consent

X-Ray Consent It is recommended that children have check-up (bitewing) x-rays at each 6 months recall appointment. This is required so that the doctor is able to diagnose any new decay in your child’s mouth since their last visit. The policy holder is responsible for outstanding balance if insurance does not cover additional set of [...]

Records Release

Ross Fishman, DMD, MS Board Certified in Pediatric Dentistry Practice Limited to Children and Teens Records Release Form I hereby authorize Fishman Pediatric Dentistry to release all dental radiographs for: Patient Name* First Last DOB* MM slash DD slash YYYY Patient Name First Last DOB MM slash DD slash YYYY Patient Name First Last DOB [...]

Post Appointment Survey

Patient Screening Form: Pre-Appointment

Patient Screening Form: In-Office

Notice of Privacy Policy

Fishman Pediatric Dentistry As a patient at this office, the doctor and assistants will obtain information about you and record it in a health record with your consent. The practice is permitted by Federal Privacy Laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected [...]