• I agree to be responsible for payment of all services rendered on my behalf or my dependents.  I understand that payment is due at the time of service unless other arrangements have been made.

I have read and understand the Financial Policy

• I authorize assignment of dental benefits to Avondale Dental (DBA Medure Dental).  I understand insurance coverage is only an estimation and I agree to be responsible for all treatment fees not covered by dental carrier for myself and dependents.

I have read and understand the Insurance Policy

• Our practice is dedicated to quality care and exceptional service.  We value your time and work very hard to schedule appointments that accommodate the busy scheduling needs of all our patients.  In return, we ask that you make every effort to arrive on time and keep your reserved dental appointment.
• Late cancellations and missed appointments create scheduling problems for other patients as well as the practice.  Keeping this in mind, we ask for a minimum of 48 hours' notice for any appointment changes.  A charge may be applied for late cancellations and missed appointments without advance notice

I have read and understand the Appointment and Scheduling Policy.

• In the event I drop off or allow my minor child to transport themselves to receive dental services, I hereby consent the doctors and staff, to clean and provide dental treatment to my child.

I have read and understand the Minor Drop Off Policy