Treatment Consent Form

Patient Name(Required)
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I, the parent or legal guardian, hereby consent to the following financial arrangements for dental services provided by Goldfields Family Dental:

Treatment Plan:

I understand and agree to the treatment plan proposed which includes a description of the recommended dental procedures, their associated costs, and any potential additional treatments that may be required.

Insurance Information:

I acknowledge that it is my responsibility to provide accurate and up-to-date insurance information. I understand that I am responsible for any deductibles, co-payments, or services not covered by my insurance plan.

Payment Responsibility:

I agree to be financially responsible for all charges incurred for the dental services provided. This includes charges that may exceed the coverage limits of my insurance plan.

Payment Options:

I understand that payment is due at the time of service. Accepted forms of payment include Visa, MasterCard or debit. Options for payment plans are available.

Missed Appointments:

I acknowledge that missed appointments or cancellations with insufficient notice may result in a cancellation fee, as outlined by the dental office's policy.


I authorize the release of any necessary information to my insurance company for the purpose of processing claims.

I have read and understand the terms outlined in this Dental Financial Consent Form. By signing below, I agree to abide by these financial arrangements.

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