OFFICE POLICY CONSENT FORM

Patient Name*

Dentist Name*

When an appointment is made, that time is specifically reserved for you only and will not be given to anyone else unless you call and cancel. It costs us approximately $400 per hour to keep our office open. When enough notice is not given (minimum 48 hours) to cancel, a $50 charge will apply (insurance plans do not cover this amount). Office policy is that: services are paid for each visit as they are performed. However, in certain circumstances arrangements for payment may be made by consulting doctor.

Please indicate one of the following with check mark.

I will like to know the total fee for all the work to be done, as well as the number of appointments necessary, so that I can pay equal portions at each appointment.I wish to discuss special arrangements for payment with the doctor.

CONSENT FOR TREATMENT:
This is to certify that I, {patientName} undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable including the use of general anaesthetic as indicated and I will assume responsibility for fees associated with those procedures.

I authorize this office to contact my previous dentist, medical doctor(s), insurance company, plan administrative at work and share information as needed. As well as, to submit insurance claims electronically.

CONSENT FOR COMMUNICATION: I would like to receive my appointments Pre-confirmation/confirmation by

E-mailSMSHome PhoneCell Phone

Patient Name: {patientName}

Patient Signature

Dentist Name: {dentistName}

Dentist Signature

DateTime