EZ Dental | New Patient Forms

I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits.

I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment is due in full at time of treatment unless prior arrangements have been approved.

I, the undersigned, have insurance with the company listed below and assign directly to EZ DENTAL all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid for by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

By avoiding billing costs, we can offer our patients quality dentistry at affordable prices. In order to maintain these fees, we request that payment is to be made at the time of service, unless other arrangements have been made in advance.

I agree that patient/parents/guardians are responsible for all fees and services rendered for treatment of patient/minor/child. I accept full financial responsibility for all charges not covered by insurance.

I, being the parent or guardian of the named minor/child below, do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.

A minimum charge will be made for failed or cancelled appointments without 24 hour notice.

I have received a copy of the dental office's Notice Privacy Act (HIPPA).

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Thank you for choosing our practice for your dental care and oral health needs.

Our policies are intended to help provide you with quality dental care and personalized attention. For your safety, please inform us of any changes to your health or prescribed medications before your visit.

As a courtesy to our clients, we accept assignment from your insurance carrier and will bill directly to them for you. Payment for your portion is due at the time of treatment. For procedures involving a laboratory component, a deposit will be required when treatment is started. We offer payment by Visa, MasterCard, Debit and Cash for your convenience.

We are an amalgam-free office and use tooth colored (white) composite filling material for direct restorations. Some insurance carriers will not cover the cost of "white fillings" and will pay the amount charged for amalgam. If this happens, you are responsible to pay the difference, which will depend on the extend of the filling required.

We accept most dental plans and we will utilize the plan to maximize your benefits. However, we prefer to prescribe the best dental treatment for each client regardless of the participation of the dental plan. We encourage you to be completely familiar with the terms of your dental insurance plan. This is a contract between you and your dental insurance. With your approval, pre-determination of insurance benefits can be obtained in advance from your insurance company by our office. The amount settled by the insurance company may be affected by such facts as annual limits of coverage, non-covered procedures, etc. Each company carries a different plan and this makes it extremely difficult for us to be aware of each and every plan detail. We will do our best to assist you with your plan when at all possible, but it is important to understand that you are ultimately responsible for your payment of any treatment.

If you find that you are unable to keep your scheduled appointment, you are required two business days (48 hours) notice so that we may accomodate the dental needs of other patients. A charge of $50.00 per hour of dental hygienist's time will be applied to your account, if we do not receive the two (2) business days' notice to change your appointment time.

Your signature below indicates that you have read and understood the above and are aware of the policies in our office.