I certify that I have read and understand the above and that the information given on this form
is accurate. I understand the importance of a truthful health history and that my dentist and
his/her team will rely on this information for treating me. I acknowledge that my questions, if
any, about inquires set forth above have been answered to my satisfaction. I will not hold my
dentist, or any other member of his/her team, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
• I consent and agree to be financially responsible for payment of all dental services and that
estimated co-pays and deductibles are expected at the time of service. This office will help
prepare insurance forms, assist in making collections from insurance companies, and will credit
any collections to patient accounts. A service charge of 1.5% per month (18% per annum) on
any unpaid balance will be charged on all accounts exceeding 60 days, unless previously written
financial arrangements are satisfied.
• I understand that any fee estimate for dental care can only be extended for a period of 6 months.
• I understand that doctor time is reserved specific for my care. I may be charged $40 for broken
appointments without 24 hour notice.