PERMISSION FOR DENTAL TREATMENT
I give my permission to Dr. Gonzalo Hernandez, DDS,and/or Dr. Alexandra Wetzel,DDS to perform all necessary procedures.
Dental Haven requests a parent or guardian present for all appointments for children under the age of 18.
I understand that if I am not present at my child’s appointment, this may limit what treatment is performed at the appointment.
In the event my child needs treatment, Dr. Gonzo, Dr. Alexandra, and/or staff will inform of the different types of methods of restorative treatment.
I understand there is no guarantee of success or permanence to the treatment. If I have any questions regarding treatment, procedures, or insurance,
it is my responsibility to make sure my questions have been answered by Dental Haven or my insurance company prior to signing the proposed treatment plan consent form.
I, therefore, understand the above statement and consent to the use of procedures if deemed necessary by Dr. Gonzo or Dr. Alexandra.
The parent or guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.
In most cases, insurance does not cover the full cost of services. It is designed to reduce your cost, but not to eliminate it completely.
Our staff will help you receive the maximum benefit available under your policy. However, please remember you are fully responsible for all fees charged by this
office regardless of insurance coverage.
We submit all claims to your insurance company after each appointment. The balance that is not covered by insurance is due on the date of service. The following methods of payment are available:
**Cash or check
Should you need copies of dental records, there is a $4.00 processing fee for technician time, materials, and postage.
If ortho models need to be copied, the fee is $55.00.
Any cancellation without giving 24 hours notice or failure to keep the appointment will result in a charge of $55.00.
I have read and hereby agree that I am ultimately responsible for payment of this account.