I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.
I consent to the dentist’s use and disclosure of my records (or my child’s records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment.
My consent to disclosure of records shall be effective until I revoke it in writing.
I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor.
To allow us to provide quality and timely service to all of our patients, a minimum of 48 business hours is required when calling to cancel or reschedule a confirmed appointment. By signing below I acknowledge that I will be assessed a fee of $100 (applied automatically) for each occurrence.
I attest to the accuracy of the information on this page.