The Patient (Guardian) agrees to notify Dr. Dressler if any changes occur in their medical/health history. The Patient (Guardian) agrees to be fully responsible for the total payments of procedures performed in this office including any amounts, which are not covered by any dental insurance or other payment programs. We allow 90 days for the payment of insurance coverage thereafter it is the patient’s responsibility of payment. In the event of nonpayment of treatment cost the Patient (Guardian) agrees to be responsible for any collection fees, attorney fees, or other fees necessary to collect the Patient’s (Guardian’s) account. In the process of reviewing this information, we may find it necessary to obtain a copy of your credit through a credit-reporting agency. I authorize the release of medical and dental information to insurance carriers and to other health care providers involved in the care of this patient.
I have read and thoroughly understand the above policies of this office.