Emergency Contact or Responsible Party if under the age of 18 

Reason for current appointment: 

For Women

INSURANCE INFORMATION: 

PRIMARY PLAN 

SECONDARY PLAN 

No Plan

I understand that payment is due at the time treatment is rendered. No exceptions.  

Cancellation Policy: 

It is our optimal goal to provide you and your family​​ with the highest quality of dental care, while maintaining a frilly and lacing environment. To keep me standard of care to a level which best serves your dental needs, ask that you observe the following: 
 
Our clinic requires a minimum of 2 business days' notice if an appointment must be canceled or rescheduled. A short notice cancellation by one patient means another patient who is suffering or is in pain has missed an opportunity to be seen by the doctor, We feel very strongly about it and to deter people from such practice, we assess a fee of $75.00 to any short notice cancellation: Exception homer will be code for illness or personal tragedy. 
 
In the event that a patient does not show up to their scheduled appointment on a second occasion, we may ask the patient to find a different dental office to serve them at which point our administrative staff will be happy to forward the patient's records to the new dental office  
 
Please note: Insurance companies do not cover the cost of missed or cancelled appointments; therefore, payment is made the patient’s responsibility prior to rescheduling. 
 
Patient Acknowledgements: 
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health or other pertinent information, I will inform the doctors at my next appointment without fail. 
 
 By initialing the insurance information, I am acknowledging that I have read and understood the statement pertaining to my insurance status 
 
I have read and understood the cancellation policy 
 
Treatment Policy: I authorize the doctor to take X-rays, study models, photographs, or other diagnostic materials deemed appropriate by the doctor to make a thorough diagnosis of my dental health condition. Upon my verbal agreement following discussion of recommended treatment, I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the services required for my dental health. I further authorize and consent that the doctor chooses and employs such assistance as deemed fit. 
 

(Parent or Guardian if the patient is under 18)