2. I understand that the use of anesthetics and sedatives may be necessary and with their use embodies certain risks. I am aware that by my request, I am entitled to a complete recital of potential complications.

3. I am aware that as a courtesy South Meadows Dental staff will bill my dental insurance. It is not uncommon for insurance companies to have wait periods for certain procedures. It is my responsibility to review my plan booklet or check with my insurance company to know my available benefits.

4. I agree to be responsible for payments of all services rendered on behalf of myself or my dependants. I understand that payment is due at the time of service and our in-office financing is limited to a 90 day period. A long term payment program is also available.

5. I am aware if there are balances that remain on my account past 90 days, I will be charged a late fee of 18% APR.

6. I agree to notify the office as soon as possible if something arises and I need to reschedule an appointment. We would appreciate a 48 hour notification if possible.

7. If required, I authorize South Meadows Dental to check my credit.

8. I have read/received a copy of the HIPPA privacy policy and understand.