Please list any additional adults authorized to bring patient to appointments to consent to dental treatment.
(No need to list parent or legal guardians)
Initial Consent to use of Records: I hereby give my permission for the use of any dental / orthodontic records for purposes of professional consultations, research, education, and / or publication in professional journals.Initial Authorization to release information: I hereby authorize the release of any medical information necessary to process all claims for charges incurred at Starting Point Dental Services, PA. Initial Financial Agreement: I agree that I am financially responsible for all charges not covered by my insurance company, included but not limited to dental services deemed routine, elective or not medically necessary by my insurance company and/or any co-pays, deductibles, co-insurance amounts or non-covered items specified by my insurance company, which will be due and collected at time of service. I assign payment directly to Starting Point Dental Services, PA for the dental benefits, if any, otherwise payable to me for services as described above but not to exceed my indebtedness to Starting Point Dental Services, PA for those services. Initial Note to Privacy Practices: I acknowledge that I have read and understood the content of the Notice of Privacy Practices.