This is to certify that I, the undersigned, consent to the dental and oral surgical procedures agreed to by myself (or guardian) and the dentist to be necessary or advisable, including the use of local anesthetic and radiographs as indicated. I understand that I am responsible for payment for all treatment rendered. I grant the dentist the right to release health information obtained from me and information about my dental treatment to health practitioners in emergency situations.
1. Payment is due at the time of service. Acceptable forms of payments include cash, check or credit card (Visa, Mastercard, Discover and American Express). Third party financing is accepted in the form of Care Credit.
2. Balances older than 30 days may be subject to additional collection fees and interest charges of 2% per month or 18% annually. Returned checks will be assessed additional fees and will be turned over to the county attorney’s office for collection if not paid timely.
3. In the event the account is not paid, and we refer the account to collection, you will be responsible for all fees incurred for collection of your bill (i.e., attorney fees, court costs, and collection agency fees).
4. Your appointment time has been reserved exclusively for you. Any change in your appointment affects many patients. 24-hour notice is needed to avoid a charge.
5. As a courtesy to you we will help you process your insurance claims. We are not a Medicare or Medicaid provider and cannot file claims to either. Please understand that we will provide an estimate to you, but it is not a guarantee of payment. If your insurance company has not made payment within 60 days, we ask that you contact your insurance company for payment. If payment is not received or your claim is denied, you will be responsible for the full amount at that time.
I have read and I understand the above information. I understand I am responsible (regardless of my insurance) for any charges incurred from services rendered.
