• Patient Information

    CONFIDENTIAL
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  • Responsible Party

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  • I certify that I have read and understand the above information to the best of my knowledge. I understand that I am responsible to pay as services rendered. I understand that I am responsible for any fees that will acquire for legal action being taken to collect my debt. I further understand that if a payment becomes 30 days past due, delinquency at the lesser of the annual rate 18% , or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due. I acknowledge that there is a fee for bounced and checks and that I may lose my rights to use checks. Our office is entitled to a minimum of 48 hours cancellation notice. We reserve the right to charge cancellation fees for missed or broken appointments. 

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  • Insurance Information

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  • I authorize and request my insurance company to pay directly to the dentist of dental group insurance benefits otherwise payable to me, I acknowledge that after thirty-days my account may acquire interest. After 45 days if insurance does not pay. I will be responsible for my account. 

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