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  • Consent for Services

    As a condition of your treatment by this office, financial arrangements must be made in advance. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.

    I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the said Dentist or Dental entity.

    A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

    I understand that the fee estimate listed for this dental care can only be extended for a period of three months from the date of the patient examination.

    I have received Notice of Privacy Practices for Newman Springs Dental Care.

    In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

    To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. I authorize the staff of Newman Springs Dental Care to use photographs, x-rays and treatment records for the purpose of teaching, marketing, research and scientific publications.

    I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

    I have read the above conditions of treatment and agree to their content.

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