To protect your privacy, our office follows legal policies and procedures. Your responses are confidential and used solely for our records. We may ask follow-up questions about your health to ensure appropriate care. We do not use this information to discriminate.

Do you have, or have you had any of the following:

I understand that I am responsible to pay Gentle Dental for any treatment performed in this office, in case my insurance should neglect payment. I understand that I am responsible for any outstanding balance. I will also take responsibility for any balances due to any collection agency. If any prosthodontics ( Bridges, crowns, dentures) are not able to be completed due to patients missed appointments, the patient will be held responsible. A fee of $50 will be charged to the patient's account if cancelation notice is not given 24 hours prior to the appointment. I authorize Gentle Dental to submit dental claims to my Dental Insurance company in order to get pay for my dental treatment.