Patient Consent For Services Payment

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As a condition of the patient's treatment by this office, financial arrangements must be made in advance. The practice depends upon payment by the patient, the patient's financial guarantor, or reimbursement from the patient's insurance for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that the insurance company is in a contract with the insured and not the dentist. Therefore, all dental services furnished are charged directly to the patient and he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge may apply on unpaid balances exceeding 60 days unless financial arrangements have been made previously. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

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Copyright 2015, Curtis Marketing Group, Inc. Do not use without written permission from Curtis Marketing Group, Inc.


  • Curtis Group
  • 9402 November Dr
  • St. Joseph, MN 56374
  • Phone: 1-320-363-0210
  • Fax: 1-320-363-0218
  • Email: Email Curtis Group