PAYMENT PREFERENCE:

These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition but they are all associated with proper oral health care.

MEDICAL HISTORY:

DENTAL HISTORY:

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail. inform the doctor at my next appointment.

As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for in cash at the time services are performed.

I understand that dental services furnished to me are charged directly to me and that I am personally responsible for the payment of all dental services.  If I  carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges il be paid by an insurance company.

Assignment of insurance: I hereby authorize my insurance company to pay directly to my dentist benefits accruing tome under my policy.

A service charge of 1.5 % per month (18% per annum) (but in no event more than the maximum rate permissible under state la) will be charged on the unpaid principal balance on all accounts not paid within 60 days of the treatment date.

I understand that the fee estimate listed for this dental case can only be extended for a period of six months from the date of the patient's examination.

In consideration of the professional services rendered to me, or  at my  request,  by  the  Doctor and/or  his  staff,  I  agree to pay,  therefore,  the reasonable value of said services to said Doctor,  or his assignee,  at the time, said services are rendered,  or within five (5) days of billing if credit shall be extended.

I further agree that the reasonable value of said services shall be billed unless objected to by me, in writing, within the time for payment thereof.

Additionally, I agree that a waiver for any breach of any term or condition here under shall not constitute a waiver of any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be enlisted to recover all costs incurred including reasonable attorney‘s and/or collection fees.

i grant my permission to you, or your assigns, to telephone me at home or at my work to discuss matters related to this form. 

I have read the above conditions of treatment and agree to their content.

We require 48 hour cancellation notice for all appointments. An $85.00 fee will be charged for a missed appointment.

I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health History form to administer such anesthetics, analgesics, and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics and/or drugs.

All services are rendered and accepted under the terms and conditions printed on the reverse hereof: Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally competent.