Consent for Treatment – The undersigned hereby authorizes Dentist to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Dentist make thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mind, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a finance charge will be added to any overdue balance. I also assign all insurance benefits to the Doctor.

Insurance – I understand that the portion of my treatment not covered by insurance is due and payable at each visit. I also understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Dentist, and that I am still responsible for all dental fees. If my insurance company has NOT PAID within 60 DAYS of being properly billed, I understand that the balance will become due and payable from me.