Has the child had any history of, or conditions related to, any of the following? Check all that apply
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my/my child’s health.
It is my responsibility to inform the dental office of any changes in medical status.
1. I understand that acceptance of this agreement means I am solely responsible for payment of the total cost of service regardless of any limitations of my insurance coverage. We will file a pre-treatment estimate with your insurance company at your request.
2. The patient's estimated portion is based only on the benefit information from your insurance. It is not a guarantee of actual benefit payment. All estimated co-pays and deductibles are due at the time of service.
3. Interest-free financing is also available after qualifying.
4. A finance charge of 1.25% (15%APR), per month with a minimum charge of $.50 per month will be applicable on account balances after 90 days.
5. According to the HIPPA guidelines, Fifth Avenue Dental has my permission to submit dental claims to my insurance and referral doctors. Contact us for a copy.
6. Fifth Avenue Dental only discloses personal information for the reasons listed above.
7. Fifth Avenue Dental confirms appointments via text, email, or auto-dial.
I acknowledge that I have read and understood this agreement and agree to the terms stated above.