Are you allergic to, or had a reaction to any of the following:
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician / gynecologist for assistance
regarding additional methods of birth control.
I certify that I have read and I understand the questions above. I will
not hold the doctors of Perry Endodontics, P.C. or any other member of
their staff, responsible for any errors or omissions that I have made in
the completion of this form.
All fees are due upon completion of treatment. I hereby authorize payment
to Perry Endodontics, P.C. of the benefits otherwise payable to me. If
you have any dental and/or medical insurance we will be glad to fill out
the proper forms, but please complete the identifying information on this
Please remember that insurance is considered a method of reimbursing the
patient for fees paid to the doctor and is not a substitute for payment.
Some companies pay fixed allowances for certain procedures and others pay
a percentage of the charge.
It is your responsibility to pay any deductible amount, co-insurance or
any other balance not paid for by your insurance company. You will be responsible
for all collection costs, attorneys fees, and court costs.
This signature on file is my authorization for the release of information
necessary to process my claim. I hereby authorize payment to Perry Endodontics,
P.C.of the benefits otherwise payable to me.
I hereby acknowledge that a copy of this office's Notice of Privacy
Practices has been made available to me. I have been given the opportunity
to ask any questions I may have regarding this Notice.