I authorize dental treatment for the minor whose name is shown above, and I accept full financial responsibility for all charges incurred in this office.
Privacy Notification: I have been informed ofoffice privacy policies and I authorized the use of protected personal information about myself and my child in accordance with these policies
I have reviewed the above clinical examination pertaining to my child's medical history and agree that it is accurate and complete to the best of my knowledge.
We hope that you understand the necessity of these charges for patients who fail appointment. This is to help protect you from increased fees to cover the cost of patients who do not keep their appointments.
Please read the following; if you have any questions please ask. In the past we have found that most credit and collection problems are caused by a lack of communication.
Full payment for professional services is due at the time of treatment. All patients without dental insurance are required to pay in full at the time of service. We offer a 5% discount for accounts paid in full at time of service with cash, check or money order. Insurance, credit and debit card transactions are ineligible for this discount.
Family Dental Group is an independent dental clinic. This means we are not a network provider for any insurance company. Patients who have dental insurance are responsible for all charges. Full payment, for all services, is due at time of treatment. If your insurance allows assignment of benefits and pays us directly, only deductibles and our estimated copayments are due at each visit. Patients are reponsible for full payments on accounts over 60 days even if an insurance claim is outstanding.