General Release
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have no knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment.
I understand that if I miss an appointment or provide less than 48 hours( 2 days)notice to cancel or reschedule an appointment, I will be charged a cancellation fee.Please note that insurance companies do not cover fees for missed/canceled appointments. Therefore, it will be patient's responsibility to pay such fees.
I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment of dental diagnostic procedures.We will assist you in preparing insurance claim forms, along with requesting reimbursements from your insurance company, on your behalf. Be aware that not all services may be covered by your insurance company, no two plans are the same. We will work with you to help clarify your plan. However, it is the responsibility of the patient to understand his or her own dental insurance benefits. Services are to be paid for at each visit as they are performed.
I have read and fully understand the above terms and conditions and I accept my responsibility as a patient at this office.
