All professional services are charged to the patient. Necessary forms will be completed to expedite insurance carrier payments. THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE.

AUTHORIZATION AND ASSIGNMENT (Please read and sign).

I hereby authorize Sonrisa – A Periodental Spa to furnish information to insurance carriers concerning my illness or injury and treatments and I hereby assign to the dentists all payments for dental services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance.

In consideration of services rendered, or to be rendered, I agree to pay all accumulated charges not covered by insurance, including an additional 1.5% late charge (18% APR) in the event that payments are not received by agreed upon dates. In the event of default on said payment, I hereby agree that reasonable attorney fees for collection of the above amount may be added.