As a condition of treatment by this office, I understand financial arrangements must be made in advance. All emergency dental services, or any services performed without prior financial arrangement, must be paid for in cash at the time of service.
I understand that dental services rendered are charged directly to me and that I am personally responsible for payment for all dental services performed.
If I carry insurance, I understand that this office will help prepare forms to assist in making collections from insurance companies and will credit such collections to my account.
I authorize the dental office to release any information, including the diagnosis and records of any dental treatment rendered, to third party payers or other health care practitioners.
I authorize my insurance company to pay directly to the dental office for any exam or treatment rendered to my dependents or me from benefits accruing to me under my dental policy.
I understand that my dental insurance carrier may pay less than the actual estimate given to me for the services rendered. My benefits are based purely on a contract between my insurance company and myself. I agree to be responsible for full payment on all services rendered to my dependents or me.
I authorize this dental office to call or text me on my home, work or cell phone to discuss relevant treatment, account and insurance information. I can withdraw my consent anytime.
A photocopy of this form shall be considered as effective and valid as the original.
I have read the above conditions and agree to their content.
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