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MF

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How Did You Hear About Our Office?

Do You Prefer To Be Contacted For Appointment Confirmation Via E-Mail or Phone?:
E-mailPhone

Insurance – Primary

Subscriber Name:

Relationship to Patient:

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Insurance – Secondary

Subscriber Name:

Relationship to Patient:

Subscriber DOB:

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Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to NOVA Dental Studio all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Patient/Guardian Name:

Today's Date:

CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. To avoid a broken appointment charge of $75 for each hour, or any portion of an hour, with a hygienist, and $100 or each hour, or any portion of an hour, with Dr Paesani, PLEASE notify us of a cancellation no less than 24 hours, or one full business day, prior to your appointment. Voicemails left over the weekend will not constitute adequate notice and will result in a broken appointment charge.

Patient/Guardian Name:

Today's Date: