Signature will be recorded later.
Date: 5/12/2024Last Name:First Name:Birthdate:* For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
* I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.
* If sent to collections, I agree to pay all related fees and court costs.
* Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.
* I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due
* I will pay a minimal fee of $25 for appointments broken without 24 hours notice.
* Treatment plans may change, and I will be responsible for the work actually done.
* I have received (or have been offered) a copy of the Dental Materials Fact Sheet.
*I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock.Financial Agreement/Assignment and Release
Office Policy Consent