Attestation & Signature Page "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Appointment CancellationsAs a courtesy, we make every effort to confirm your appointment one day in advance. However it should be noted it is your responsibility to keep all appointments. We request a minimum of 48 hours to change or cancel an appointment. A fee will be incurred for all failed or late cancellations.Dental InsuranceIf you have insurance coverage, our staff does their best to determine a proper estimate for you. We cannot always predict the actual payments your insurance carrier will make. You are required to make payment of your full estimated responsibility upon services rendered. After payments are received from your insurance carrier, you may be required to make additional payments or have a credit issued to you. Authorization and ReleaseI certify that the information provided is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child during the period of such dental care to third party payers and/or health practitioners.Additional InformationOnly a licensed dentist may perform certain procedures pursuant to 234 CMR 2.04 (15). If you have any questions concerning the licensure of the person treating you, you may request to see their license. If you have any questions concerning a specific procedure, you may request whether the procedure is one that is restricted to a licensed dentist.Privacy Practices AcknowledgementI acknowledge receipt of Notice of Privacy Practices.Patient / Parent / Guardian SignatureDate MM slash DD slash YYYY * I understand that my information will be transmitted securely and used only for my care. Read Our practice's Privacy Policy / Notice of Privacy Practices Δ
