I consent to receive dental treatment from Fisher Pointe Dental. I hereby authorize payment directly to Fisher Pointe Dental of any dental services performed from the insurance company I provide. I shall be legally responsible for any out of pockets costs, such as co-pays, deductibles and services that may not be a covered benefit under the policy. I authorize Fisher Pointe Dental to release any medical information requested in the course of my treatments to my dental insurance company.
I hereby acknowledge review of the Privacy Statement offered at Fisher Pointe Dental and understand a copy can be provided to me. My signature is authorization for Fisher Pointe Dental staff to contact me according to the following instructions: