TO THE PATIENT (OR ADULT GUARDIAN) Please read the following statements carefully and initial where indicated.

I understand payment is due in full at the conclusion of every appointment. I understand that it is my responsibility to complete my financial obligations immediately. In the event that I have dental insurance I understand that Dr. Parent’s office will provide me with the information to gain any possible benefit from my insurance company.

We accept MasterCard, Visa, American Express and Discover credit cards, personal checks as well as cash.

I understand that if I must cancel my appointment, notice of this cancellation must be given during business hours at least one weekday in advance. Missed appointments and/or cancellations done less than 24 hours before my scheduled appointment time may result in a fee up to 50% of the scheduled procedure. Missed or late cancellation hygiene appointments will result in a fee of $135.

I understand that every medical/dental treatment carries risks and benefits. I understand that if I do not comprehend the entirety of risks and benefits of a procedure that it is my right to inquire.

I understand that I may be given a local anesthetic injection and that in rare instances patients have had an allergic or adverse reaction to the anesthetic, temporary or permanent injury to nerves and/or blood vessels from the injection. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from holding my mouth open during treatment.

I have read and understand the payment policy and agree to abide by its guidelines.