Medical History Form

Medical History Form
First Name*
Last Name*
Preferred Name*
Which pronouns do you prefer?
Do you have Dental Insurance

Financial Agreement

I acknowledge full responsibility for payment of services and agree to pay for them in full. I authorize my insurance carrier to issue any benefits directly to this office and I also authorize release of information necessary to process insurance claims. I understand the payment of services is my responsibility . I understand that if my insurance does not pay their portion within 6 weeks of treatment I am then responsible for any outstanding account balances. All unpaid balances are subject to a service charge not to exceed 9% per month. Account balances are then subject to a service charge not to exceed 9% for every month the account balance remains unpaid.

I understand there is a $100.00 fee for appointments cancelled with less than 24 hours notice. I understand that if I pay any outstanding balance with a credit/debit card that there is a $3.00
transaction fee automatically added.

PARENTS OF MINOR CHILDREN: It is the policy of this office that the parent who brings the child to the first appointment is responsible for any account balances. I understand this office does not bill multiple households for treatment rendered on minor children. It is the responsibility of the parents of said child to work together to pay any outstanding balance.