I grant authority to the Dentist to perform procedures and treatment, including administration of medicine, local and general anesthetics, and extractions along with other surgical and dental procedures that may be necessary. I have received (or have been offered) a copy of this office’s Notice of Privacy Practices and “The Dental Materials Fact Sheet”. By signing this form, you are giving this office your consent to use and disclose health information about you for treatment, payment, and health care operation purposes.
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. If your insurance carrier does not remit payment within 60 days, the balance will be due and payable by you. Please have your completed insurance claim form with you at the first visit.