We will file all necessary forms and reports to your insurance company. We do not render our services on the basis that the insurance company pay our fee. The patient/patient's guardian is personally responsible for any fee the insurance company does not cover.
Serious Illness History
CANCELLATION POLICY: There will be a charge for any appointments missed without 24 hour notice. I understand that I will be responsible for this charge. PAYMENT POLICY: Payment must be made at the time services are rendered unless prior arrangements are made. I understand that I am ultimately responsible for the balance on my account. If I fail to meet the requirements, I know this matter will be turned over to an outside collection agency and legal charges may be filed against me. CONSENT TO TREATMENT: I authorize Dr. Blaess and her staff to perform procedures including, but not limited to prophylaxis (cleaning), taking X-Ray and photographs, administering anesthetics and/or medications, restoring (filing) teeth, removing teeth, endodontics (root canal) treatment and other procedures he/she may deem necessary for my/my child's proper care. To the best of my knowledge all the above answers are true and correct. If any of the information changes I will inform the dentist at my next visit.