I certify that I, and/or my dependents(s), have insurance coverage with the above company(ies) and assign directly to Dr. Preston Poole all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Dr. Preston Poole may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. As a courtesy, we will file your dental insurance. I understand that I a m responsible for payment of services rendered, regardless of my insurance benefit. I understand I am responsible for all late charges after 45 days and collection and attorney fees for unpaid balances.

I have reviewed the Notice of Privacy Practices.

Any appointment that is broken or canceled without a 24 hour notice will be charged a fee of $50 per hour scheduled. We are sympathetic to unavoidable emergencies. In order to avoid your account being charged, our office must receive notice at least 24 hours in advance should it be necessary to reschedule your appointment by phone, voicemail, or email