EMERGENCY NOTIFICATION INFORMATION

TREATMENT AUTHORIZATION AND ACKNOWLEDGEMENT

I consent to treatment as necessary or desirable for the care of the patient first named on the front of this form. This authorization provides for the utilization of procedures necessary for the diagnosis and treatment of dental disease, deformity, and dental emergency. These procedures may include (and not be limited to) intraoral and extraoral examinations, radiographs, dental casts and photographs. I give my consent to the use of local anesthetics for pain relief during treatment and understand that the practice of dentistry involves the responses of living tissues and a perfect result cannot be guaranteed.

I authorize the utilization and transfer (including electronic) of my photographs and dental records to doctors, dental laboratory technicians, students and patients for the benefit of treatment and education.

In the case of a dental emergency, I consent to treatment as deemed necessary by the Doctor for myself and/or my child, understanding that the procedures will be explained in advance if I am available and conscious. If I am not available or conscious, I authorize the Doctor to provide emergency treatment for me and my family as deemed appropriate by the Doctor.

I grant the Conifer Dental Group the right to release my dental and medical treatment histories and other information to third-party payers and/or other health professionals.

I acknowledge full responsibility for the payment of services and agree to pay for them, in full, at the time of service, unless other arrangements are made in advance. To avoid a misunderstanding regarding dental insurance, all professional services rendered are charged directly to the patient and patients are personally responsible for payment of fees. We will prepare necessary forms or reports to help you obtain insurance benefits upon receipt of payment of fees. We do not render services on the basis that insurance companies will pay all fees.

I understand SERVICE CHARGES will be applied to any unpaid balances incurred by my family and me at a periodic rate of 1.5% per month even if they are subject to payment by insurance companies. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorneys fees incurred in the collection of the account.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.