Patient Information Form (Test Page)

Release

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of .any information concerning my (or my child's) healthcare, advice and treatment provided for the purpose of administering claims for insurance benefits. I authorize release of any information concerning my (or my child's) healthcare, advice and treatment to another health care professional. I hereby authorize payment of insurance directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand that I am financially responsible for payment in full of all accounts. By signing this agreement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor. I understand that fees for professional services are due at time of service. I understand that account balances over 60 days past due are subject to a monthly rebilling fee. I understand that 48 hours notice is required when canceling/changing an appointment. I understand that there may be a $50 fee incurred for broken appointments. I attest to the accuracy of the information on this page.

Do You Now, Or Have You Ever Had, Any of the Conditions Listed