A service charge of 4% per month may be charged to accounts exceeding 30 days. There will may be a monetary charge for appointments cancelled without at least 48 hours advance notice from the time of the scheduled appointment. We cannot guarantee appointments for patients who arrive more than15 minutes late of their scheduled appointment.

5I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowing omitted any information. I give my permission to telephone or email me to discuss matters related to this form. I have hadthe opportunity to ask questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.