Patient Information

Spouse or Responsible Party Information

Employment Information

INsurance

Secondary (If Applicable)

REFERRAL

Consent for service

As a condition of your treatment by this office financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time of services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the parent/guardian of the patient and that he or she is personally responsible for payment of all dental services. This has been given permission to help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patients account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1.5 % per month (18% annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the doctor, I agree to pay therefore the reasonable value of said services to said doctor, or his assignee, at the time said services are rendered of within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any tie or condition hereunder shall not constitutes a waiver of any further term or condition as I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their consent.

Acknowledgement of Receipt of Notice of Privacy Practices

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I have received a copy of this office's Notice of Privacy Practices. Note: Please download the Notice of Privacy Practices from the link provided at the top of this page.

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