Please sign the form at the end and submit.
Payment is due upon completion of treatment. Please note that all services may not be covered by insurance coverage. It is patient's responsibility to cover the procedures that are not covered by their insurance plan.
I, first and last name* , shall inform the dentist and staff at the next appointment without fail, if I have any changes in my health status or if my medications change. To the best of my knowledge, all the preceding answers are correct.