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Name and Phone # of 2 persons whom we may contact in case of emergency
Name of previous dentist where records could be obtained, if necessary
Whom may we thank for this referral?
PAYMENT IS DUE AS SERVICES ARE RENDERED. We will gladly file your insurance claim for you. A service charge of .66% per month (7.92% annually) will be automatically added to any balance over 60 days. A $25.00 fee will be charged on all returned checks.
I understand that responsibility for payment for dental services provided in this office for myself, or my dependents, is mine, due and payable at the time services are rendered unless financial arrangements have been made. If insured, I authorize any insurance payment to go directly to Dr. Robert Derr.
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