Patient Form Pg4


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.

I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that I am financially responsible for payment in full of all services rendered, regardless of what my medical aid or payer of my dental benefits pays. By signing this statement, I acknowledge that I received a copy of the financial policy of this office and I agree to the terms set forth in the policy.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

I grant my permission to you and your assignee, to telephone me at home or at my work to discuss matters related to this form and my account.

I consent to the use of the provided email address(es) for appointment reminders and any other direct communication from this office.

I have read the above conditions of treatment and payment and agree to their content.

Patient, Parent or Guardian

Relationship to Patient

Guarantor of payment/responsible party

Relationship to Patient
Right to Revoke: You will have the right to revoke these Consents at any time by submitting to our office in writing, notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

View Financial Policy
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