PATIENT INFORMATION - MINOR
THIS INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL
Driver's license no.
Social security no.
Name of nearest relative not living with you
Name of physician
Purpose of appointment
Whom may we thank for referring you?
Person responsible for this account
Preference of payment;
Insured person's name
Secondary insurance co.
Insured person's name
CONSENT FOR TREATMENT: I HEREBY GRANT AUTHORITY TO THE DENTIST (S) IN CHARGE OF THE CARE OF THE PATIENT WHOSE NAME APPEARS ON THIS FORM, TO ADMINISTER SUCH ANESTHETICS, ANALGESICS, SEDATIVES, OR NITROUS OXIDE SEDATION; AND TO PERFORM SUCH OPERATIONS AS MAY BE DEEMED NECESSARY OR ADVISABLE IN THE DIAGNOSIS AND TREATMENT OF THIS PATIENT. I HAVE BEEN INFORMED OF ALL POSSIBLE COMPLICATIONS OF THE PROCEDURES, ANESTHETICS AND / OR DRUGS.
I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE CARRIERS
I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR
I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL
Our financial policy is payment is due at the time of treatment. We will inform you of the fee of your recommended treatment at the time it is diagnosed. And offer financing options.
We believe these options will prove to be a service to you and your family.
A 5% reduction in your fee if you pay for services in advance of the treatment being initiated.
Payment by appointment. This option allows you to spread out the payments according to your treatment plan.
Payment with Mastercard, Visa, Discover and American Express. This will allow you to comfortably budget your monthly payments.
Insurance on assignment. As a service to you, we will continue to file your insurance and accept assignment of benefit from your insurance company. This will help reduce your immediate 'out of pocket' expenditures - only the estimated private pay monies will be due at the time of treatment
Long term or extended financing will be offered through Care Credit. This is our new financial partner that will allow our patients to invest in their oral health with small monthly payments over an extended period of time.
A finance charge of 18% may be added to outstanding balances.
I understand that all responsibility for payment for dental services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered.
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