We only use tooth colored (resin) fillings in our office and will not replace Silver/Mercury containing fillings in our patient’s teeth. Should your insurance co. provide a benefit for white filling based on the equivalent of a Silver/Mercury filling, you are still responsible for a difference.
CONSENT- PLEASE READ BEFORE SIGNING
I undersigned hereby authorize the Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of patient’s needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents antibodies a certain risk. I also give full permission for dental services to be rendered upon my child under the age of 18 if I decide not to be present for my child’s scheduled appointment.
2023 FINANCIAL POLICY
We accept Cash, Visa, MasterCard, American Express, Discover, Money Orders, Personal Checks or CareCredit.
CONSENT- PLEASE READ BEFORE SIGNING
I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I understand that ESTIMATED FEES given by the office are based on information from my insurance company. I have read and understand all of the information above.