I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.

I (patient, parent or guardian) authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to the patient. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for the payments of all services rendered on my behalf or dependents. I authorize One67 Dental to immediately process any outstanding balance under $200.00 towards the credit card as indicated below. Any outstanding balances owing that are over $200.00 will be processing in monthly increments of $200.00 until balance is fully paid. I am aware I will be contacted regarding my outstanding balance and any payment not processed within 90 days, unless otherwise discussed with management, will be deemed uncollectable and forwarded to a collection agency.

I agree and am aware of the $50.00 fee if I fail to show to my dental appointment or need to cancel or reschedule an appointment within less than 2 business days.