Consent
INSURANCE ASSIGNMENT AND RELEASE:
I certify that I, and/or my dependents have insurance coverage with the insurance company provided to the office and assign directly to Vast Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all chargers whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above named dentist may use my health care information and may disclose such information to the above named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or two years from the date of this signature.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied.
DENTAL CONSENT:
I hereby authorize Dr. Hoang and his/her associates to provide dental services, prescribe, dispense and/or administer any drugs, medications, antibiotics, local anesthetic, and expose radiographs that he/she or his/her associates deem, in their professional judgment, necessary or appropriate in my care. I realize that it is mandatory that I follow any instructions given by my dentist and/or his/her associates and take any medications as directed.
I fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, local anesthetic, and any dental treatment. The most common risks can include, but are not limited to:
Bleeding, swelling, bruising, discomfort, stiff jaw, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest.
I have read the above conditions, dental consent, and agree to their content.