This is typically the nearest relative who does not live with the patient
Person Responsible for Account
Please check if the patient has a history of the following medical conditions:
Does the patient have, or ever had, any of the following habits?
Acknowledgement of Financial Responsibility
Here are some important things you should know about our practice and your Dental Insurance Plan:
Your dental benefits are based upon a contract made between your employer and an insurance company. Dental benefit plans will never completely pay for all your treatment. Dental insurance is only to assist you in paying for your dental treatment.
We maintain computerized histories of payments made by a given insurance plan. Plans, however, can and do change, therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have. It is only an ESTIMATE.
We will bill your insurance as a courtesy. If insurance does not pay within 90 days, Dental Spa of Texas reserves the right to request payment in full. You will need to collect the payment due to you from your insurance company. The insurance you have is a legal contract. You are responsible for all charges incurred in our office.
We do require payment in full for your portion at the time of service. We accept Visa, MasterCard, Discover, American Express and Cash. We do NOT accept checks.
A designated appointment time will be reserved specifically for you and your treatment needs. If you must change your appointment, we require at least a 24-hour notice to avoid a $50.00 cancellation fee.
I have read the above statements, and I understand and agree to each statement.
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.