All previous information is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.
I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behold of my dependents (if any), within 30 days of treatment. Any payments not received within the 30 days will result in a 10% interest charge that will be charged every 30 DAYS until the balance is paid in full.
I understand that if I do not provide a 24 HOUR notice for cancelling an appointment, I will be charged a fee of 95.00. Your time is valuable, just as ours is.