In order to comply with the Occupational Safely & Health Administration Blood borne Pathogen Regulation (OSHA), we are requesting your consent to submit for testing of your blood for (blood borne pathogens Hepatitis B, Hepatitis C, or HIV) IF ANY EXPOSURE OCCURS (needle stick injury, blood splatter) to one of our staff members or doctors. Testing will be done at no cost to you. All information regarding an exposure is confidential and you consent stating you will come back if called.

In order to comply with the new privacy rules governing the sharing of medical information for billing purposes, we need your permission. Please sign this form in the line below to allow for the billing of insurance for your care. Please initial the appropriate blocks for additional permissions.

May leave message on my voice mail/answering machines.

May fax information to my fax number and/or work number.

May email me at

May share information with the following member of my family:

We value your time as much as we value ours. With this in mind we block time for your treatment. It is not possible for us to fill in an appointment due to a cancellation if we do not have adequate notice. We will therefore be enforcing our policy that is clearly stated below.

Anytime you are scheduled for a consultation appointment and need to reschedule or cancel us need 24 hour notice. For all broken appointments a $75.00 fee will be applied.

A 48 hour notice is required to cancel or reschedule your surgery or consultation with surgery appointment. If not, there will be a charge of $250.00 towards broken appointment fee. The above policy will apply to all patients who are making an appointment within the next 48 hours for surgery. Please acknowledge that you understand and accept our policy by signing at the bottom.

Your medical and dental insurance is a contract between you and the insurance company. All contracts are different. Insurance policies state what the company is willing to pay towards your health care. The insurance company does not determine what treatment is necessary or in your best interest. That decision is made only by your doctor.

Claims may be rejected as “not covered benefit” or “no authorization”, etc. This does not mean your treatment was not necessary.

You are responsible for your health and your health care cost. For your convenience our office will work with you to utilize your insurance coverage. Please understand that when we speak to your insurance company on the phone and they tell us they will cover a certain percentage of their usual and customary THIS IS NOT A GUARANTEE OF PAYMENT BUT AN ESTIMATE. If the insurance company denies the claim for whatever reason, you will be responsible for the remaining balance. Please note that our estimated financial is done as a COURTESY. Overall it will be YOUR RESPONSIBILITY to keep your account up to date and call with any questions. Please note your account will be sent to collections if we receive no reply to the statements (two) that are sent to you. You will be responsible for the accrued 8% interest and attorney fees.

If Patient is a Minor