Patient Information Form

Health history

Consent for Services

All dental services performed, including emergency dental services must be PAIN IN FULL at all time services are performed. We accept Cash, Check, Master Card, Visa or Discover.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all services.

I AM RESPONSIBLE FOR THE BALANCE IF ANY OF THE FOLLOWING OCCURS:

• The treatment goes over my yearly maximum.
• My Insurance Company denies any treatment.
• I am not eligible for insurance.
• I prevent or delay payment by not complying with requests for insurance forms, signatures or additinal information.
• I received an insurance check and did not send it to the office for payment claim.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

I grant my permission to you or your assignee to telephone me to discuss this statement or my treatment.