Consent for Services
As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash/check/credit card at the time services are performed unless other arrangements are made.
Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
In consideration for the professional services rendered to me at this practice, I agree to pay the charges for the services at the time of treatment, or within ten (10) days of billing, I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. A $10.00 late payment fee may be added at our discretion to late accounts, unless previously written financial arrangements are satisfied.
I have read the above conditions of treatment and payment and agree to their content.
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