I authorize the specialist to conduct a dental examination and perform the treatment as deemed necessary for proper dental care.
I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.
I understand that I am responsible for payments in full for all professional services at the time each service is performed. I understand that an estimate of treatment costs will be given to all new and recall patients and that the actual cost for services may be higher or lower. By signing this form, I revoke all previous agreements to the contrary and agree to be responsible for payment of service not paid in whole or in part by my dental care provider.
I authorize the communication and release of information concerning my (my child’s) related treatment to other dentists or specialists.
I authorize the communication and release of information contained in my claim forms to my insurance provider/plan administrator.
APPOINTMENT POLICY: Our policy requires that if you wish to cancel an appointment, you must provide our office with 48 hours notice. Appointment cancellations with less than 48 hours' notice are subject to charges.
I have read the above conditions and agree to their content.