I give my consent to needed dental services and accept responsibility for payment of all services performed.
I agree to notify this office of any change in the patient's medical history and/or medication.
I authorize payment of insurance benefits directly to Chattahoochee Valley Dental.
I understand that I am ultimately responsible for any remaining balance on my account due to policy exclusions or limitations.
I accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees (33.33%), attorney fees and/or court costs, if such be necessary.
I acknowledge an appointment is a reservation. I agree to provide a minimum of 48 hours notice if I need to change my appointment for any reason. I understand a minimum of $25 will be charged to my account. This charge can be as high as half of my portion after insurance.
I agree, in order for Chattahoochee Valley Dental to service my account or to collect monies I may owe, Chattahoochee Valley Dental and/or their agents may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in charges to me by my carrier. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.
The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire and widely used by sleep professionals in quantifying the level of how likely are you to doze off or fall asleep in the following situations, in contrast to feeling "just tired". This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you. Please select the most appropriate number for each situation.
I authorize the above mentioned dental provider to release my dental records to Chattahoochee Valley Dental.