Treatment Consent Form

Patient Name(Required)
DD slash MM slash YYYY

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.

Authorization:

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.

DD slash MM slash YYYY
Call Today