Thank you for choosing PDAA! Please do not exit the webpage until you’ve reached "Online scheduling complete!" screen. We will collect your preferred payment method, child's procedure information, and child’s medical history on the following screens. Please enter in the information accurately.
I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of network providers. I wish to waive any limit on balance billing and receive treatment from this out of network provider.
I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance company. I understand that my insurance plan may not cover any part of the charges, costs or expenses related to Anesthesia services and I will be responsible for all charges incurred.
Patient Name:
Date of Birth:
Dentist:
Procedure Date:
Parent Name:
Dentist Office:
Procedure Minutes:
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