I certify that I have read and understand the above information 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 authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors, and/or health practitioners..
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I understand that during the course of the procedure(s), unforeseen conditions may arise which necessitate procedures different from those contemplated. I, therefore, consent to the performance of additional procedure(s).
I understand that I am responsible for all fees regardless of insurance coverage.
I also understand that as treatment progresses the above fees may have to be adjusted, but that I will be informed of these adjustments and how they will affect my payment.
In the event that my payments are not received within 30 days of their due date, I agree to pay all costs of collections, including, but not limited to reasonable attorney's fees.