Who is responsible for your account?
In the case of an emergency, is there anyone, not living with you, that we may contact?
For your convenience, we offer the following methods of payment. Please check the method(s) you will be using.
*(If your check is dishonored or returned for ANY reason, we reserve the right to electronically debit your account for the amount of the check plus a processing fee of $35.)
I authorize the dentist or any of her staff to release any information including records of any treatment or examination rendered to me or my child during the period of such Dental Care to third party payors and/or other health practitioners. I agree to be responsible for payment of all services rendered on behalf of myself and/or my dependents*.
*If I do not pay the entire balance within 30 days of the service date, a late charge of 1.9% will accrue on any unpaid portion of the balance each month. I also realize that failure to keep this account current will result in our office being unable to provide additional dental services. In the case of default of payment of this account, I agree to pay any collection costs and attorney fees incurred in attempting to collect on this amount or any future outstanding balances. I authorize and request my insurance company to pay directly to the dentist or dental group, insurance benefits unless stated differently on the claim form. I understand that my dental insurance carrier may pay less or nothing of the actual bill for services rendered. I agree to be responsible for payment of ALL services rendered on my behalf or my dependents.
** If this is a medical emergency, please call 911 immediately! **