(please bring current dental insurance card and driver’s license to appointments)

I hereby authorize the release of any information to my insurance company or companies, including records of examinations, diagnosis and/or treatment. This release is solely for facilitating the billing and reimbursement, directly to Chesterfield Family Dental of insurance benefits under which I am entitled. I hereby agree that I am financially responsible for all treatment rendered, and understand that complete payment will be made after each treatment, unless other financial arrangements have been previously arranged.

I hereby authorize Chesterfield Family Dental to take the necessary x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Chesterfield Family Dental to make a thorough diagnosis of the patient’s dental needs, lab needs; and for the use of dental education, which may include full face or smile photos. I waive any claim which might accrue to me personally on the account of the use of such photographs, x-rays. I also authorize Chesterfield Family Dental to perform all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between me and the insurance carrier and not between Chesterfield Family Dental and your insurance company. I fully understand that it is my financial responsibility only for the dental treatment regardless of insurance coverage. I understand that if my account is turned over to a collections agency due to non-payment, I will be responsible to pay all cost of collection, court and legal fees in addition to the balance owed.