Please select “YES” or “NO” if your child has/had:
Please select “YES” or “NO” if you have/had:
I certify that the above information is true to the best of my knowledge. The above questions have been accurately answered. I understand that providing
incorrect information can be dangerous to my health. I consent to the taking of photographs and x-rays before, during and after treatment. I have read &
understand the Notice of Privacy Practices (HIPPA), which is posted in the waiting room and/or available upon request.
I understand that dentistry is not an exact science and that, therefore, reputable practioners cannot fully guarantee results. I acknowledge that no
guarantee or assurance as been made by anyone regarding dental treatment, which I have requested and authorized.
I agree to be responsible for payment of all services rendered on my behalf or my dependents in the event that my dental insurance carrier pays less than
the actual bill for services. A finance charge may be imposed on my account if it has not been paid within 30 days of the time the treatment was completed.
The finance charge will be computed at the rate of 1.5% per month or an annual percentage rate of 18%
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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