I am financially responsible for any balances due on the day of treatment, and authorize the dentist to release any information for insurance claims to the insurance company on my behalf. In consideration of the services rendered to me by this office I am obligated to pay said office in accordance with its credit terms and policy. I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
I also authorize the dentist to use my email and or cell phone number to confirm/re-schedule appointments, send enewsletters or any vital electronic information that may help me keep informed about my oral health. I understand that I can unsubscribe at any time.