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.
