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781.340.5437 (KIDS) | fax: 781.340.5438
5 Federal Street, Weymouth, MA 02188
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Our Policies and Forms

We commit to providing quality, compassionate and professional care for your child using the latest techniques and equipment in a fun, clean and positive environment. In order to maintain these high standards and a harmonious relationship, we would like to communicate clearly regarding our office policies and forms. If at any time you have questions, please feel free to ask our staff or call our office. We are here to help in any way we can. We appreciate you entrusting your child’s dental health to us.


For Our New Patients:

Our office is paperless, in an effort to be green, we recommend that you become familiarized with these forms and arrive 10-15 minutes prior to your scheduled appointment to complete these on our computer.

• New patients medical history form

• HIPPA Notice of Privacy Act

• HIPPA Authorization of Release of Protected Health Information

• HIPPA Acknowledged of Receipt of HIPPA

• Appointment policy, please see our high-light:

* Please bring your child’s most current insurance card to every appointment

* Parent or legal guardian MUST be present at the time of each appointment. If not, a consent form needs to be signed by parent or guardian granting permission to other present individual.

* The scheduled appointment is reserved specifically for your child

* We kindly request a 48 hours in advance notice if a cancellation is unavoidable so that we may give it to another patient. Less than 48 hours notice, we reserve the right to charge $75.00 broken appointment fee per child in your account.

• Financial policy, please see our high-light

* Payment (co-payment and deductible) is expected in full for each appointment as services are rendered. For your convenience, we accept cash, American Express, Master Card, VISA, Discover and Care Credit

* The parent or guardian bringing the child to South Shore Pediatric Dentistry, LLC is considered the person legally responsible for payment of all charges. We cannot send statements to other persons

* If we have received all of your dental insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. Please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. We also cannot be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.

* If your account balance is past due, no new treatment will be initiated. A past due balance of 90 days without activity will result in inactivation as a patient and family in our practice.


For Orthodontic Appointment:

• Informed consent for orthodontic patients

• Orthodontic emergency flyer (what to do in case of loose brackets, wires etc.)

• Keeping your teeth clean: a “must” during orthodontic treatment


For Nitrous Oxide / Oxygen Sedation Appointment:

• Pre-op and post-op instructions for nitrous oxide/oxygen sedation

• Consent form for use of Nitrous oxide/oxygen sedation


For General Anesthesia Appointment at Franciscan Hospital for Children:

• Franciscan Hospital for Children Pre-Op Instructions

• Franciscan Hospital for Children Post-Op Instructions


For Oral Surgery Appointment:

• Informed consent for dental extraction (oral surgery)

• Post-op instructions for dental extraction


Other Forms:

• Consent for treatment accompanied by non-parent/ non-guardian adult



Our Location: 5 Federal Street, Weymouth, MA 02188
Tel: 781.340.5437 (KIDS)
Fax: 781.340.5438