Consent for Treatment Form

Please correct the errors described below.

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.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance/Medicaid coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney’s and collection fees. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins.

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