I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the Dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the Dentist.
I authorize the insurance company indicated on this form to pay the Dentist 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.
We are proud to participate in your dental healthcare, and have set aside time for your appointment. We understand that sometimes it is necessary to cancel or change your appointment. In consideration of others who need care, we ask that if you are unable to keep an appointment with our office, that you please observe our cancellation policy, which follows
Our office requires at least 24 hours notice for all appointment cancellations. If you are unable to provide 24 hours notice, you will be billed a $50.00 charge for the scheduled appointment time. Emergency situations will be handled at the Doctor's discretion.
If you are unable to keep your appointment scheduled for the next day and our office is closed, you may cancel by leaving a message for us on our voicemail. The 24-hour rule still applies.
By checking the box below you are agreeing that you've read our "Authorization" and "Cancellation Notice", that you understand it and agree to the policies stated. Both the checkbox and your signature are required.