The above information is true and correct to the best of my knowledge:
The undersigned hereby authorizes doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient's dental needs. I also authorize doctor to perform all recommended treatments mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that doctor chooses and employs such assistance as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for dental services provided in this office for any dependents or myself is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event, payments are not received by the agreed-upon dates. I understand that a 1-1/2% finance charge (18% APR) may be added to my account. In the event the patient neglects to pay balance on account, the patient could be subject to any associated attorney's and collection fees.
HIPAA Privacy Disclosure:
Our office will make every effort to keep the information that we have on file confidential according to the Health Insurance Portability and Accountability Act (HIPAA) that went into effect April 14, 2003. Complete HIPAA file is available upon request.