• Bradford Family Dentistry Family, Cosmetic, Implants, & Sedation
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  • Responsible Party Information:
  • This is the account guarantor and this person MUST sign below
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  • Dental Insurance Information:
  • Please complete information even if you"ve presented a card to us
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  • If yes, please present your card at your first visit.
  • Financial Agreement:
  • * I understand payment is due at the time of service. If I have dental insurance, I agree to pay my estimated out-of- pocket expenses at the time of treatment. * I understand all balances over 60 days are subject to a 1.5% per month billing cycle. * I agree to be responsible for all charges which remain unpaid by my insurance after 45 days.
  • Payment Options:
  • * Cash, Check or Credit Card at time of service * Auto monthly deduction from credit or debit card * Extend Payment Plan (OAC) * Payment in full prior to treatment: 5% discount (cash/check only)
  • I hereby authorize and direct Bradford Family Dentistry, as assisted by other dentists and auxiliaries, to perform any necessary dental treatment.
  • All patients under the age of 18 must have a parent or legal guardian present for all scheduled appointments.
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  • Patient/Guardian Signature (Account Guarantor)       Date
  • [Signature Completed At First Office Visit]
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  • Should be Empty: