I, the undersigned, hereby authorize the Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the Patients dental needs. I, upon being clearly informed by the Doctor, also authorize the Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with the undersigned or any person for whom the undersigned is responsible (i.e., dependent child), and further authorize and consent that the Doctor choose and employ such assistance as they deem appropriate. I also understand the use of anesthetic agents embodies a certain risk - minor though it may be. I also consent to the release of treatment information as necessary to my insurance or third party benefit provider, in effort to procure financial assistance.
I understand that resposibility for payment for Dental Services provided in this office for myself, and/or my dependents, is mine, due and payable at the time services are rendered. I further understand that a 1.5% finance charge (18%APR) may be added to any balance over 30 days. In the event of default, I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.
Cancellations are discouraged because they interfere with the continuity of your treatment. If you must cancel, please give a 48 working hour courtesy notice in order that another person may benefit from the time reserved for you. If you fail to give 48 working hour notice of cancellations, you may be obligated to pay a fee for that appointment. (Please note that insurance companies will not pay for missed appointments.) Generally, fee waivers are granted only in cases of true emergiencies.
I have read and have an understanding of the about patient guidelines.