Health Questionnaire Consent & Financial Policy
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that Dr. Williams and his staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold Dr. Williams or his staff responsible for any action they may or may not take because of errors or omissions that I may have made in the completion of this form. Since a change of medical condition or medications can affect dental treatment, I understand the importance of and agree to notify Dr. Williams of any changes at any subsequent appointment. I authorize Dr. Williams and Pinecrest Dental to perform all general preventive and operative treatment procedures necessary to maintain my oral and dental health including administration of local or topical anesthetics, nitrous oxide, or prescription drugs for pain, infection, or medical condition. You also expressly authorize us, and any other person or entity who provides goods or services to you in connection with this agreement, to contact you by sending text messages or emails to any of your telephone numbers or e-mail accounts. Methods of contact may include the use of pre-recorded/artificial voice messages and/or the use of an automatic telephone dialing system, as applicable. You acknowledge and agree that this authorization shall extend to any billing or collection company or companies which may be assigned your account(s) for servicing or collection. I also authorize Pinecrest Dental to send dental appointment reminders via text message and/or email.
All dental services must be paid for at the time services are rendered. If you have insurance, your portion must be paid for at the time of service, unless financial arrangements are made prior to treatment. If I elect for a payment plan, I authorize Pinecrest Dental to run a credit report (after receiving an estimate signed and in writing) on my behalf.
This agreement also allows Pinecrest Dental to share my information with third party insurance companies in order to complete claims submission. I authorize Pinecrest Dental to share my first and last name, and photo in promotional welcome emails, newsletters and direct mail (Address, Date of Birth, SSN, medical history etc. will never be shared with anyone except for licensed medical and/or dental insurance companies). We will gladly help prepare and submit the insurance forms of patients and will credit any such payments received from your insurance plan to the patient's account. However, this office cannot render services on the assumption that our charges will be paid in full by any insurance company. Even though you have insurance, you are personally responsible for payment of dental services whether or not your insurance pays the claim.
Terms: Net 30 days. Interest at the rate of 1.5% per month (18% annually), will be charged on all past due balances. In the event the account is delinquent and satisfactory arrangements have not been made for payment, all legal fees, attorney fees, court costs, including charges and collection agency fees of up to 50% of the balance assigned, with or without suit 45 days after non-payment.
Please note: We ask 2 days notice for reservation changes. Broken reservations without 2 days notification are subject to a $150 fee.