*PLEASE NOTIFY OUR FRONT DESK IF YOU HAVE SECONDARY INSURANCE*
I AUTHORIZE TREATMENT OF THE PERSON NAMED ABOVE AND AGREE TO PAY ALL FEES AND CHARGES FOR TREATMENT. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR INFORMING KING FAMILY DENTAL CARE ABOUT ANY CHANGES IN MY HEALTH HISTORY PRIOR TO TREATMENT. PATIENTS WITH INSURANCE ARE RESPONSIBLE FOR THEIR PORTION OF THEIR BILL AT THE TIME OF SERVICE. KING FAMILY DENTAL CARE DOES NOT HAVE CONTRACTS WITH ANY INSURANCE CARRIERS, THEREFORE WE REQUIRE THAT YOUR ESTIMATED SHARE BE PAID NOW. I HEREBY AUTHORIZE PAYMENT OF MY GROUP INSURANCE BENEFITS TO KING FAMILY DENTAL CARE.
TO THE PATIENT: Your answers are important for the protection of your health and that of the staff of King Family Dental Care. Please answer the following questions about your health. If you have now or have had any of the following conditions, special precautions may be needed during your dental treatment. Your answers are important for your treatment. ALL ANSWERS ARE STRICTLY CONFIDENTIAL
PLEASE NOTE: in combination with antibiotics your Birth Control Pills can become INEFFECTIVE.