Fillable New Patient Information Form (Page 2 of 2) in pdf

APPOINTMENT POLICY

When you make an appointment with our office, we consider this a mutual commitment and reserve

appropriate facilities and staff exclusively for you. Our office policy states that patients must give us 1

business day or 24 hours notice if they cannot keep an appointment. Appointment changes with less

than 1 days notice are subject to a service fee based on the number of staff members and the amount

of time that was reserved for you.

FINANCIAL POLICY

Payment in full is due the day of treatment, or on upon the start of major treatment. Should a patient have

dental insurance with assignment to Dr. Gavin Forsyth Inc, the estimated patient portion will be the

amount due.

Payment Options

1. For your convenience we accept Cash, Debit, Visa, MasterCard.

2. We also offer short-term financing options but interest charges will apply. All arrangements must be

made in advance and are subject to an approval process.

For Patients with Dental Insurance

Dental insurance plans often pay less than the actual fee for service. Therefore the patient or Guarantor

is the responsible party for all dental services provided. Dental insurance in most cases is a benefit with

You are ultimately responsible for

limitations and should not be expected to take care of all costs.

all costs incurred regardless of what your dental insurance covers!

Finance Charge and Fees

• Balances in excess of 30 days are subject to a finance charge of 2% per month (24% per annum).

• Returned checks are subject to a $25 accounting fee.

AUTHORIZATION AND CONSENT

General Consent to Treatment

I agree and consent to a dental examination by Dr. Gavin Forsyth or an Associate of Clear Dental. I

understand that additional diagnostic procedures and dental treatments may be recommended and will be

discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or

implied, as to the results of any procedures or dental treatments performed.

Release of Information

I authorize Clear Dental to release any information regarding my dental/medical history, diagnosis or

treatment to third party payors and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Dr. Gavin Forsyth Inc and

Associates.

I understand and will comply with office Appointment Policy.

I understand and will comply with the office Financial Policy.

I understand and agree to the General Consent to Treatment.

I authorize the Release of Information.

I authorize the Assignment of Insurance Benefits.

X ___________________________________________ Date _______________________

Signature of patient, parent or guardian

New Patient Information Form Page 2