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.