I understand that the information on the Registration, Medical History, and Dental History forms are necessary to provide dental care in a safe and efficient manner. I have answered the questions to the best of my knowledge. Should further information be needed, the staff of EPIC has my permission to ask the respective Health/Dental care provider to release such information. I will notify this office of any changes in my health or medications.

If payment for services rendered is not made in a timely manner, your account may be turned over to an outside collection agency and you will be responsible for collection fees. A $25 fee will be charged for insufficient funds on returned checks. A late (less than 48 hours) cancellation fee of 10% of your surgery amount may apply. The late (less than 48 hours) fee for cancelled maintenance appointments is $50.

I understand that I am financially responsible for all charges regardless of insurance coverage.