Consent for Services

I, the undersigned, do consent to all dental services rendered in The FamLee Dentist PLLC practice. All dental services include, but are not limited to: examination, diagnosis, prophylaxis, radiographs, restorations, periodontal maintenance. I further consent to all policies aforementioned.

I grant my permission to you and your assignee to telephone me to discuss treatment within the bounds of HIPPA compliance. I authorize my information to be shared only with myself and any person(s) with whom I have given specific written permission to do so.

I authorize the diagnosis of my dental health by means of radiograph, study models, photographs, or other diagnostic tools deemed appropriate for treatment.

I authorize the practice to release personal health information for myself and dependents to third-party insurance carriers, payors, and/or healthcare practitioners for the betterment of my care. I authorize my insurance carrier to submit payment directly to the dentist or dental practice and for it to be applied directly to any outstanding balance on my account.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect, inaccurate, or misleading information has the potential of being hazardous to my health. Consent and all authorization for services are valid for two (2) calendar years.