Consent For Treatment and Office Policies

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Cinema Dental Care 661-253-3030

Consent For Treatment and Office Policies
Please read carefully and sign with your initials on the line at the left.
___________ I hereby authorize the Doctor or designated staff to take X-rays, cast models,

photographs and other diagnostic aids deemed appropriate by Doctor to make a

thorough diagnosis of ___________________________’s dental needs.

Name of Patient
____________ I authorize Cinema Dental Care to use my cast models, photographs or x-rays taken in the office for demonstrations, lectures and or publications.
____________ Upon such diagnosis, I authorize Doctor to perform all recommended treatment mutually agreed upon by me and to employ assistance as requires to provide proper care.
___________ I agree to the use of anesthetics, sedatives and other medications as necessary. I fully understand that using anesthetics agents embody certain risks. I understand that I can ask for a complete recital of any possible complications.
___________ I authorize Cinema Dental Care to file all claims on my behalf. I fully understand that any quotes provided me by Cinema Dental Care are only estimates and any fees not paid by my dental insurance become my fully responsibility.
___________ I agree and understand that a fee of $25.00 may be charged if I request a copy of my dental X-rays or treatment history.
__________ I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other agreements have been made. In the event that payments are not received by agreed upon dates, I understand that my account may be referred to a collection agency.
__________ I understand that in the event I need to cancel my appointment. I must provide at least 24 hours notification and if failure to do so may result in penalty of $25.00.

Date: _______________________

Patient/Guardian Signature: ___________________________
Relationship to Patient: ______________________________
Witness: __________________________________________

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