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Consent for Treatment

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Consent for Treatment( * mandatory to fill )
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of consent: By signing this form, you are acknowledging that you have received adequate information about the proposed treatment, that all your questions have been answered fully and that you understand that every reasonable effort will be made to insure your condition is treated properly, although it is not possible to predict results.

You may obtain a copy of our consent forms for each individual. procedure at any time by contacting our client
 
Right to revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on the consent before we received your revocation. Pursuant to MDA dental protocols, we can not treat you without your consent.
 
if this consent is signed by a personal representative on behalf of the patient, complete the following:
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( * mandatory to fill )

Authorization For Release Of Information For Insurance Purposes

 

I hereby authorize the release of any information necessary to process my insurance claim and any payment insurance benefits otherwise payable to me, be made to the attending dentist. A copy of this signature is as valid as the original... I, the undersigned, understand and agree that there will be an interest charge of 1.5% per month of any past due to account over thirty days. I also understand and agree that if am in default of this agreement, I will pay all reasonable legal fees, court costs, and other costs necessary to collect the debt, including fees charged by a collection agency.

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