I understand that I am responsible for all costs of dental treatment. Payment is due at the time of services. If I do not pay the entire new balance within 25 days of monthly billing date, a service charge (1.5% per month, 18% annually) will be added to the account. The information on this page and the dental/medical histories are correct to the best of my knowledge. I hereby authorize the Dental Office to administer such medications and perform such diagnosis and therapeutic procedures as may be necessary for proper dental care. I hereby authorize payment of insurance benefits to be made directly to the Dental Office otherwise payable to me. A copy of the dental materials fact sheets and the office’s privacy policies have been made available to me. I grant the right to the dentist to release my dental/medical history and other information about my dental treatment to third party and/or other health professionals. I understand that if I am unable to keep this appointment, I will give a minimum of 48 hours’ notice or I will be responsible for the charge for time reserved.