This agreement is to inform you of your financial obligation to our practice. Please understand that payment of your bill is considered a part of your treatment. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health.

All charges you incur are your responsibility regardless of any insurance coverage or benefit plan that may assist you in completing your dental treatment. Additionally, our practice will charge you a fee of $75 for appointments that you do not keep and for appointments that you do not cancel with 48-hour notice.

We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. As a courtesy to you we will complete your insurance claims and submit to your insurance for payment. In order for our practice to seek reimbursement from your insurance company, we ask that you please provide us with all insurance information needed.

GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Midtown Dental Group to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient’s dental condition and needs. I authorize Midtown Dental Group to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Midtown Dental Group choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Midtown Dental Group. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status.

FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Midtown Dental Group and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.