New Patient Form

Secondary Insurance

I understand the above information and guarantee this form was completed to the best of my knowledge and have not made any deliberate omissions.  I authorize the staff to perform any necessary services needed during diagnosis and treatment.

I consent to your disclosures of my information, which you deem necessary, in connection with my treatment.

I hereby authorize the use of my signature below on all insurance submissions and authorize the dentist to release all necessary information to secure payment for treatment rendered. I authorize payment of the dental benefits, otherwise payable to me, directly to the office of Dr. Michael Page. I fully understand that I am responsible for all costs of dental treatment whether they are covered by my insurance or not. I understand that if my account balance is not paid within 30 days I will automatically be charged a finance charge of 18% APR (1.5% monthly) unless other written financial arrangements have been made prior to my treatment. I understand that the accompanying parent (or guardian) of a minor will be responsible for full payment.

I acknowledge that the office of Kelly Family & Cosmetic Dentistry does have a Notice of Privacy Practices and I understand that I have received a copy of the Notice of Privacy Practices.

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