I hereby authorize assignment of my insurance rights and benefits to the provider for services rendered. I fully understand I am sole responsible for any balance not paid by my insurance company (if offered at this office).
DISCLAIMER: By signing your initials above, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
4 - EMERGENCY CONTACT
5 - DENTAL INFORMATION
6 - MEDICAL HISTORY & INFORMATION
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We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between the provider and patient.
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses inured in collecting your account.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
I acknowledge that I have received a copy of the Summary of Privacy Notice.
DISCLAIMER: By signing your initials and name above, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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