Healthcare Dental Agreement

HEALTHCARE DENTAL AGREEMENT

Patient Information

Male   Female   Non-binary/Other

Insurance Information

Medical History

Please indicate conditions that apply to you:

Allergies (see details below)   Diabetes   Heart disease   Bleeding disorder   Pacemaker/ICD

Current smoker/tobacco use   Pregnant or suspect pregnancy   Taking blood thinners/anticoagulants   Other chronic conditions

Proposed Treatment & Clinical Consent

I hereby authorize the dentist and dental staff to perform the procedure(s) described above. I understand that reasonable efforts have been made to explain the nature and purpose of the proposed treatment, anticipated benefits, common risks, and reasonable alternatives. Known risks and potential complications may include, but are not limited to: infection, bruising, swelling, bleeding, nerve injury, persistent numbness, need for additional procedures, and adverse reaction to medications or anesthesia. No guarantee or promise has been made regarding the results of the proposed treatment.

I acknowledge that I have had the opportunity to ask questions regarding the procedure(s) and risks, and that all my questions have been answered to my satisfaction. I understand that I may withdraw consent at any time prior to the procedure by notifying the treating dentist. I consent to performance of any additional procedures that, in the professional judgment of the dentist, are necessary or advisable in the course of treatment.

I consent to local anesthesia and/or topical agents as required for the procedure(s).
I consent to the use of conscious sedation or nitrous oxide if recommended by the dentist.

Financial Agreement & Assignment

I accept responsibility for payment of all fees charged for dental services rendered or authorized on my behalf. I understand that estimates provided are not a guarantee of coverage by my insurer and that I remain responsible for charges not paid or reimbursed by insurance. Payments are due at time of service unless alternative financial arrangements have been agreed to in writing. I agree to pay collection costs, attorney fees, and court costs if necessary to collect unpaid balances.

By signing below, I authorize my insurance benefits to be paid directly to the dental practice (assignment of benefits) and authorize the release of any information required to process claims. I understand that verifying and collecting insurance benefits is not a guarantee of payment and that credit for payment will be applied to outstanding patient balances as applicable.

HIPAA Privacy Acknowledgment & Release

I acknowledge receipt of the practice's Notice of Privacy Practices. I authorize release of my dental and medical information to my insurance company, referring provider, and other health care entities as necessary for purposes of treatment, payment, and health care operations as described in the Notice.

I acknowledge receipt of the Notice of Privacy Practices.

I authorize the release of my dental records and radiographs to third parties for treatment, referral, or insurance processing. This authorization will expire on:

Cancellation & No-Show Policy

I understand that appointments cancelled without at least 24 hours' notice or missed appointments may result in a cancellation or no-show fee. Repeated failures to attend scheduled appointments may result in termination of the dentist-patient relationship.

Acknowledgment & Authorization

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I have read and understand the foregoing, and by signing I authorize the dental practice to provide dental treatment, release information to my insurer, and bill my insurance and me for charges incurred.

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