Patient Information
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the plan and he or she is personally responsible for payment of all dental services not covered by your plan. This office will help prepare the patients' insurance forms on your behalf and submit to insurance. However, this dental office cannot render services on the assumption that our charges will be paid by your insurance company. A service charge of 2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if the suit is instituted hereunder. I grant my permission to you or your assignee, to telephone or email me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.