Consent For Treatment and Financial Agreement Form

CONSENT FOR TREATMENT

1. I hereby authorize the Doctor or designated staff to evaluate, diagnose, prevent and / or treat (nonsurgical, surgical, or related procedures) any diseases, disorders and / or conditions of the oral cavity, maxillofacial area and / or the adjacent and associated structures and their impact as it relates to myself. I also authorize the doctor to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of my medical and / or dental needs, and allow the doctor to use the aforementioned information for scientific and/or clinical purposes provided my identity is not revealed.
2. Upon such diagnosis, I authorize the Doctor to perform any and all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. This includes medically related exams, consultations, CT, and radiographs; and dentally related care such as root canal treatment, oral surgery, dental implant, and prosthetic (crowns, bridges, dentures) treatments that have been prescribed to me.
3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that the use of anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. I understand that the practice of dentistry is not an exact science and that therefore, results cannot be fully guaranteed. I understand that the teeth are living and biological structures of the human body, and complications may arise during and after any form of treatment which may require the need for a specialist.
5. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not visible during examination. The most common example of this is necessary root canal therapy or additional restorative care following routine restorative procedures. I give permission to the Doctor to make any and/or all changes and additions as necessary.

FINANCIAL AGREEMENT

1. I agree to pay all fees and charges for such treatment. I agree to pay all charges for members of my family shown by statements, promptly upon presentation thereof, unless credit arrangements are agreed upon in writing. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within 30 days of billing date. In the event legal action should become necessary to collect an unpaid balance due for dental services rendered to me or my family. I / we agree to pay reasonable attorney’s fees or other such costs as the Court deems proper.
2. It is agreed that all payments will not be delayed or withheld because of any insurance coverage or the dependency of claims thereof, and proceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. In other words, if your insurance company does not reimburse this office, you are solely responsible for all payments to this office. If any discrepancy with your insurance company should arise, we will expect you to pay within 30 days of notification of the discrepancy. A copy of this assignment is valid as the original.
3. If financial arrangements have been made and payments are delinquent, this office reserves the right to reschedule any non-emergency appointments until the account is brought to current status.
4. It is the patient’s responsibility for knowing their medical & dental insurance company coverage, even if this office is a participating provider. Not all insurance coverage is the same, even if coverage is within the same company. The patient is responsible for all co-pays and deductibles at the time of service. We reserve the right to bill your medical and dental insurance plan for any related care.
5. Forms of payment include cash, check, or credit card. Discounts or limited time offers may apply for some procedures at our company’s discretion. Our office also reserves the right to charge for appointments cancelled or broken without proper advanced notice.