New Patient Form

Consent for Services

 
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
 
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
 
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
 
I hereby assign my benefits, payable from claims submitted electronically, to the Dentist and authorize payment directly to him/her.
 
I grant my permission to you or your assignee, to telephone me at my home or at my work to discuss matters related to this form.
 
I have read the above conditions of treatment and payment and agree to their content.