Welcome to our office. We are happy that you have chosen us for your dental needs, and we will do our best to make your experience a pleasant one.
THis ONLY needs to be filled out if the patient is under 18 years.
As with most professional offices, full payment for services is expected at each visit.
We accept: Cash, Check, Credit Card (Visa, Mastercard, Discover, American Express)
Care Credit/Citi Health Card/Lending Club - offers a separate line of credit to cover your entire family's dental
We will be happy to work with you to plan the most appropriate arrangements for your budget. Financing your
treatment will allow you to begin your treatment immediately and spread the cost over a period of time.
We will gladly discuss your proposed treatment and answer any questions relating to your insurance. Please realize,
The parent or guardian accompanying a minor is responsible for full payment, regardless of any child custody and/or
medical payment responsibility by the other parent NO CHILD UNDER THE AGE OF 18 WILL BE TREATED WITHOUT A PARENT
OR LEGAL GUARDIAN PRESENT.
A service charge will be added to all deficiency balances over 45 days. You will also be liable for any reasonable
attorney and/ or collection fees and all related costs necessary to remit the balance back to this office.
If unable to keep appointment, kindly give 48 hour notice. This will give us time to schedule other patients who are in need of treatment. Any cancellation less than 48 hours, a charge of $50.00 per person will be added to your account. Payment must be made on or before new appointment. Thank you for your cooperation.
There will be a flat fee of $30 for processing & for collection cost.NOTE: There will be a processing fee of $25 for a duplicate copy of x-ray.
I understand that I may inspect or copy the protected health information described by this authorization.
I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.
I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,
I authorize this office to disclose or discuss my personal and/or dental information with the following person(s).
(Please enter name and relationship to patient)
I grant my permission to the dental practice to upload and store confidential patient information (including account
information, appointment information and clinical information) to the secured web site for the dental practice. I
understand that, for security purposes, the site requires a user ID and password for access and use. I also
understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and
password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be
incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not
liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my
authorization to allow another person or entity to access and use the dental practice web site with my ID and
password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other
need to deactivate my ID due to security concerns.
I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with
respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain
information to third parties. I understand the dental practice will represent and warrant that they will, at all
times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that
may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure,
maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their
direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve,
store, upload and use my information in connection with the operation of such services, and is acting on my behalf
in uploading my patient information. I understand the dental. practice will use commercially reasonable efforts to
maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand
the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR
OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.