I will assume responsibility for all fees associated with the procedures.

This is to certify that I consent to the performing of the dental procedures agreed to be necessary.

To the best of my knowledge, the above information is correct.

I hereby authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.

I hereby authorize direct payment to Source Dental for benefits from claims submitted electronically.

I hereby certify that I have been notified of the privacy policies of this office, who to contact regarding privacy concerns, and how to request further information.

By checking this box I confirm that Source Dental may send me emails regarding my appointment notifications, insurance/tax receipts, instructions, and other practice information. My email will not be shared with any 3rd party at any time. (Note that we use several different software programs to send out emails, so if you opt in and later decide to opt out, please call us to inform us personally). *

I consent to the use of my (child’s) image by Source Dental, which may be used on Social Media platforms managed by Source Dental, and future marketing/communications collateral. I agree that I shall have no claim against Source Dental or against anyone accessing this communications/marketing material, whether online, in print or by any other means. I confirm that I have parental consent or am over 19 years of age, and that I have not given anyone the exclusive right to use my image.