I understand that I'm personally responsible for payment of all dental services rendered.
Our practice will on your behalf help prepare patients insurance forms or assist in making collections from the insurance company and will credit any such collections to your account. Dental insurance plays a role in helping patients to acquire dental care, however it cannot interfere with the proper diagnosis and treatment recommendations. Treatment recommendations are made on your dental health needs, not on what insurance coverage you may or may not have.
I understand the fees estimated for dental care can only be extended for a period of 3 months from the date of the patient exam. The undersigned affirm that the information given in this questionnaire is true and accurate to the best of their knowledge.
I authorize the dental staff to perform such dental serivces as may be necessary and authorize the release of written records to any referring or treating dentist, physician, medical facility or insurance company for legal documentation.
I have read the above conditions of treatment and agree to their content.