Consent for Services
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. As a courtesy, Neal W Rogol DMD, Inc. will process and submit insurance claims after each visit. This dental office cannot render services on the assumption that your charges will be paid by an insurance company. The plan deductible and patient co-payments will be due at the time services are rendered.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding sixty (60) days, unless previously written financial arrangements are satisfied.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.