In consideration of professional services performed by James M. Seaver, D.D.S. and Tyler L. Pittman, D.D.S, P.C., the undersigned hereby accepts total and absolute responsibility for all costs incurred as a result of such treatment and services not covered by any acceptable insurance. In the event of default in the payment of any amount due, after thirty days, the undersigned agrees to pay a services charge in an amount not exceeding 1.8% per month on this account. Further in the event this account is referred to an attorney or collection agency, the undersigned agrees to pay reasonable attorney fees, but in no case less than $100.00, or collections fees and court costs as permitted by laws governing these transactions.
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures (such as X-rays + fluoride treatment) as may be necessary for proper dental diagnosis and care. The information on this page and the medical history are correct to the best of my knowledge.
I have read and understand the above stated policies and completed this questionnaire accurately and completely.