Preferred Appointment Time
Have you ever had any of the following? Please check those that apply.
To the best of my knowledge all preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Financial & Insurance Agreement
Payment in full is due at the time of treatment and is considered a part of your commitment to this office. For extensive treatment plans we may be able to offer small in house payment plans with written approval from the clinic and arranged prior to your treatment appointment date. We will gladly file dental claims on your behalf, but we are not a party to any insurance programs or contracts. If you have any questions regarding your insurance we recommend that you contact your dental insurance plan directly. It is important that you be familiar with your benefits to eliminate any disappointments with coverage and reimbursement. Your benefit coverage is a contract between yourself, your employer and the insurance company. Per the Privacy Act, your dental plan information is considered “confidential medical information” and as such it will not be released to us, as your dental care provider.
An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written financial agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
In order to be fair to both our team members and to all of our patients, we do require that you notify our office with at least two business days notice for any appointment changes or cancellations. Failure to provide this notice will result in a $61.00 / hour missed appointment charge.
By clicking the button below, I agree to allow Dentrix Dental to contact me via email.
Consent for Services
I hereby authorize the Dentist to perform the necessary services for prevention and treatment of dental disease and will assume responsibility for associated fees. As a condition of your treatment by this office, financial arrangements must be made in advance. I understand that dental fees can be extended for a period of 3 months from the date of service. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written financial agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.