I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (patient's name)'s dental needs.
Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
I consent to the use of appropriate medication or therapy as deemed necessar. I fully understand that using anesthetic agents embodies a certain risk.
I agree to be responsible for and understand that I am responsible for payment of all services rendered on my behalf or my dependents. I understand that I am responsible for whatever my insurance company does not pay and that payment is due at the time of service unless other arrangements have been made. In the event payments are not received within 60 days of the date of billing, I understand that a month 1 1/2% finance charge (18% APR) will be added to my account.
I authorize the rendering of diagnostic and treatment procedures, including local anesthesia, by Drs. Jimmie & Luanne Anderson, which in their professional judgement may be deemed necessary or beneficial.