Patient Form

7. Do you have or have you had any of the following?

Consent for Services

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. It is the policy of our office that payment is expected the day of service on all visits unless other arrangements have been made. There will be a charge for failed or cancelled appointments less than 24 hours.

I understand that the fee estimate listed for this dental care can only be extended for a period of 3 months from the date of the patient examination. I grant my permission to you or your assignee, to telephone me at home or at work to discuss matters related to this form.

I give permission to have Dr. Tycast complete treatment that is necessary. I have read the above conditions of treatment and payment and agree to their content. I, the undersigned, understand and agree that there will be an interest charge of 1.5% per month of any past due account over sixty days. I also understand and agree that if I am in default of this agreement, I will pay all reasonable legal fees, court costs, and other costs necessary to collect the debt, including fees charged by a collection agency.