Patient Registration

General Consent:

The undersigned hereby authorizes the doctor to use X-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's needs.

I also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with.

Patients failing to keep scheduled appointments without 24 hours notice may be charged for an office visit.

I understand that using anesthetic agents &/or nitrous oxide embodies a certain risk. Furthermore, I understand that all responsibility for payment of dental service provided in this office for myself or my dependents is mine, due & payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1.5% finance charge (18% APR) may be added to my account. I agree to pay any attorney and collection fees if this account is turned over for collection.

I understand that even though the doctor will file my insurance for me as a courtesy, I am responsible for the total amount due.

All diagnostic aids & documentation are the property of the practice. Records may not be taken by the patient. All records are confidential & will not be released without written permission of the patient, parent, or legal guardian.