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

We would like to thank you for entrusting your dental health care needs with our office. Our goal in this practice is to make you and your family feel comfortable and confident with your choice for optimal dental care. If ever a question arises during or after treatment, please be sure to ask. The following is an explanation of our financial policy:

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1 ½% late charge per month (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

For your convenience, we gladly accept payment by cash, check, Visa, MasterCard, American Express, and Discover.

I understand that if I must cancel my appointment, notice of this cancellation must be given during business hours at least one weekday (Monday-Friday) in advance, to a staff member or doctor to avoid a charge to my account. Charges for missed or canceled appointments will be determined by the doctor.

I hereby authorize doctor or designated staff to take radiographs, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs.

Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

I agree to the use of anesthetic sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

We are very pleased to have the opportunity to enhance your health and well-being by providing excellent dental care for you, your family, and friends.

I have read the financial and cancellation policy statements and I fully understand and agree to the above mentioned policies.