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Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out the attached form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help.
Payment is due in full at the time of treatment unless prior arrangements have been approved. This office accepts insurance, I understand that I am responsibleJor payment of services rendered and also responsible Jor paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office oj the group insurance benefits otherwise payable to me. I understand that I am responsible Jor all costs oj dental treatment. I hereby authorize release oj any inJormation, including the diagnosis and records oj treatment or examination rendered, to my insurance company I understand that the inJormation that I have given today is correct to the best oj my knowledge. I also understand that this inJormation will be held in the strictest confidence and it is my responsibility to inJonn this office oj any changes in my medical status. I authorize the dental staff to pe/fonn any necessary dental services that I may need dUring diagnosis and treatment, with my inJonned consent.