Your Dental Home
Welcome to Sweet Tooth Dentistry, your dental home! Our office looks forward to provide you with exceptional dental care. To assist us in serving you better, please complete both sides of the following confidential form.
I hereby authorize Sweet Tooth Dentistry to process payment to my credit card of any outstanding balance occurred during the course of dental treatment to keep my account current.
I have read or have had read to me the office policies and insurance assignment conditions. I understand that I am responsible to pay for all dental fees charged to me for services provided. My signature below is authorization of the assignment of my Dental Insurance payment to Sweet Tooth Dentistry. If my plan denies payment of my benefits to Sweet Tooth Dentistry, I agree to pay my account in full.
Your appointment will be reserved especially for you. If you are unable to keep the appointment we will require 48 hours’ notice, otherwise it will be necessary to charge for time lost.
I understand that the information that I have given today is correct to the best of my knowledge and haven’t omitted any information. I also understand that it is my responsibility to inform this office of any changes in my medical status. I have had the opportunity to ask questions and I also consent my physician being contacted if necessary. I hereby authorize the dentist or designated staff to perform diagnostic, dental and oral surgery procedures and services.