ANNUAL CONSENT FOR TREATMENT AND PAYMENT
I AUTHORIZE and give consent to Cedar Ridge Dental to perform dental services agreed between the doctor and patient and/or parent/guardian deemed to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I certify that the above statements regarding my medical history and conditions are correct to the best of my
knowledge or that there have been no significant changes to my medical history in the past 12 months.
I UNDERSTAND that as a courtesy to me, CEDAR RIDGE DENTAL will direct bill my dental insurance. I hereby authorize payment directly to CEDAR RIDGE DENTAL from my group benefits. If my insurance pays me directly, I will be responsible for the total balance and will remit payment to CEDAR RIDGE DENTAL upon receipt. In the event that my insurance does not submit payment to Cedar Ridge Dental within 45 days, I will be forwarded the bill and be required to pay the entire balance owing and will collect reimbursement from my insurance directly.