New Patient Sign Up Form

I certify that I have read and understand the above information to the best of my knowledge and the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I agree to notify the office of any changes to my health or patient information. I authorize the dentist to examine and treat me or my child, and release any information including diagnosis and records of treatment or exams rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist for insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. If I default on this agreement I agree to be responsible for all finance charges and/or collections and attorney expenses incurred. I am aware of the privacy practices and a Notice of Privacy Practices is available to me.