SECTION A: CONSENT FOR PATIENT

SECTION B: TO THE PATIENT (OR ADULT GUARDIAN)
Please read the following statements carefully

PURPOSE OF CONSENT

By signing this form, you acknowledge that you have read and understand our practice's financial policies as stated below.

FINANCIAL POLICIES

• We accept cash, credit card/ debit cards, and checks. We also accept CareCredit and Lending Club. Payment or Insurance Co-Payment is expected at the time services are rendered. If financing is required to meet financial responsibility, arrangements must be made prior to scheduling an appointment.

• Returned checks are subject to a $25.00 charge and any bank charges we incur.

• Co-pays for dependents are due on date of service. Divorced parents need to make arrangements to coordinate payment prior to appointments.

INSURANCE

• I authorize payment of dental benefits directly to the dentist. I further authorize the release of any information necessary to process these dental claims. I understand that I am financially responsible for all deductibles, co-payments and non-covered services that may apply as directed by my insurance plan. I am aware that eligibility is not a guarantee of coverage as actual benefit payments are determined only when a claim is adjudicated.

APPOINTMENTS

• It is the policy of this office to bill for any missed appointments unless given at least 24 hours notice. I understand that unless I give such notice, I will be charged $75.00 for a missed hygiene appointment and $150.00 for a missed appointment with the doctor.