Consent for Treatment:
I hereby authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:
We accept Visa, Mastercard, American Express, personal cheque and cash.
We also can process your private health fund claim at the time of your appointment but need your card at every visit.
We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit.
I understand the consent for treatment, the payment and cancellation policies as stated above.
By my electronic signature below, I agree to the terms and conditions.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status.