New Patient Form

CONSENT FOR TREATMENT

1. I hereby and voluntarily consent to such procedures, including diagnostic and treatment, as may be deemed

necessary by Associates in Dentistry .

2. I further understand that during treatment it may be necessary to change or add procedures because of conditions

found while working on the teeth that were not discovered during examination. I give my permission to Associates

in Dentistry to make any/all changes and additions as necessary

3. I understand that I have the right to question, discuss or refuse any or all tests and/or treatments before the work

has begun.

4. I understand that dentistry is not an exact science and, therefore, no guarantees or assurances have been made by

anyone regarding the dental treatment which I have requested and authorized.

5. I understand that the final opportunity to make changes to dental work such as bridges, crowns, dentures, partials,

and night guards (including shape, fit size, and color) will be before the final cementation or insertion.

6. I give consent to Associates in Dentistry and his associates to call in prescriptions and to consult with my health

care providers.

7. I acknowledge that I have had the opportunity to read this form. My questions have been answered to my

satisfaction. I understand its contents. I can receive a copy of this form upon request.

CONSENT TO RELEASE MEDICAL/DENTAL INFORMATION AND AUTHORIZATION TO PAY

INSURANCE BENEFITS

1. I authorize the release of any medical information necessary to process my insurance claims and necessary

information for billing statements.

2. I authorize the release of my name to identify work sent to medical and dental laboratories.

3. I authorize and request payment directly to Associates in Dentistry of medical/dental

benefits otherwise payable to me. They will not exceed Associates in Dentistry regular charges.

4. I understand that I am financially responsible to Associates in Dentistry for any deductible, co-insurance or non-

covered services. I further understand that once the work is initiated, I am financially

responsible.

5. I agree this authorization will cover all medical/dental services rendered until such authorization

is revoked by me through written notification.

6. I agree that a photocopy of this form may be used in lieu of the original.