madisonparkdental.com - New Patient Form

HIPPA PRIVACY
I have read and understand the regulations placed by HIPAA and have been given a copy of the Privacy Policy
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CONSENT FOR TREATMENT
I authorize the doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs. Upon diagnosis, I authorize the doctor to provide proper care. I agree to the use of anesthetics, sedatives, and any other medication as necessary. I understand I can ask for a complete recital of any possible risk or complications.
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FINANCIAL INFORMATION
Deductible, co-payments, and ant payments not covered by your insurance are due at the time of service. I authorize and request my insurance company to pay directly to the dentist otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for my services. I agree to be responsible for payment of all services rendered on behalf of myself and my dependents.

We accept cash, checks, visa, mastercard, discover, amex, cherry, and care credit.
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By signature below, I certify that the information I have provided above is complete and truth to the best of my knowledge.
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Madison Park Dental