- The undersigned hereby authorizes the doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs.
- I also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with the patient. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctor chooses and employs such assistance as deemed fit to provide the recommended treatment.
- I understand that all responsibility for payment for dental services provided in the office for my dependents and myself is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1.5% finance charge (18% APR) may be added to my account, in addition to any collection charges. All returned checks are subject to a $30.00 return check fee.
- I understand that where appropriate, credit bureau reports may be obtained.
- I understand that it is my responsibility to advise your office of any changes in the information contained on this form.
- At the office of Lakeside Dental Arts, we dedicate the appropriate time slot for your appointment in order to best take care of your needs. In return, we ask that if you are unable to keep your appointment please notify us at least 24 hours prior to your appointment time. Missed or last minute cancellations will result in a charge of $100.00.
7. In order to protect the privacy of other patients and staff and in compliance with federal and state privacy laws, the use of digital recordings by handheld devices such as smartphones are prohibited on the premises.