I understand that I am responsible for payment for Dental services provided in this office for myself or dependents. Payment is due at the time of services rendered I further understand that 1.5% finance charge (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to collect this debt.

List any Medication you are presently taking:

Have you ever had or been treated by a doctor for (check any conditions that apply)

WOMEN:

SIGNATURE OF PATIENT: I understand the need for truthful answers. To the best of my knowledge, the answers I have given are accurate. I also understand the importance to report any change in my medical/dental status to the dentist at the earliest possible time. I give my permission to the dentist to obtain any additional information from my physician.