Women:

By signing this form, I consent Advanced Dental Specialty Group's use and disclosure of my protected health information to carry out the following: treatment, payment activities, and healthcare operations.

I also consent to the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by Advanced Dental Specialty Group. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from the date signed.

If you have dental insurance, please fill out the following:

Before any treatment is performed, we will present to you at your request (assuming your insurance information is correct) an ESTIMATE of what your insurance will pay. This is ONLY AN ESTIMATE. The primary account holder is responsible for any balance the insurance company does not cover.

We are happy to serve you by submitting your insurance claims directly to your insurance company without additional charge. Accordingly, please read and sign the following agreement:

I authorize payments to be made directly to Advanced Dental Specialty Group and also authorize the release of all information relating to these claims.

I agree to full payment responsibility for all dental services not paid by the insurance company.

I agree to PAYMENT IN FULL FOR SERVICES RENDERED AT THE TIME OF THE VISIT. If the account is not paid within 90 days of the date of service, and no financial arrangements have been made, I am responsible for collection fees, legal fees, interest charges, and any other expenses incurred in collecting my account.

It is my responsibility to inform the dental office of any changes in my medical status.

I do voluntarily assume any and all possible risks, if any, which may be associated with general preventative and operative treatment procedures.

I understand that FOR ANY REGULAR APPOINTMENT CANCELLED OR FAILED WITH LESS THAN 24-HOUR NOTICE, A $75 FEE WILL APPLY, FOR ANY PRIORITY APPOINTMENTS (6-8 AM OR 4-7 PM) CANCELLED OR FAILED WITH LESS THAN 24-HOUR NOTICE. A FULL APPOINTMENT FEE WILL APPLY.

I certify that the information on this form is true and accurate.