I, the parent or legal guardian, hereby consent to the following financial arrangements for dental
services provided by Goldfields Family Dental:
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.
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
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.
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.
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
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.