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These forms are required and assist us in getting acquainted with you and your dental needs. It is important that a parent or guardian be present with any patient under the age of 18. This will save about 15 minutes of your time in our office.

Many of our patients allow family members such as their spouse, parents, or others to call and discuss dental treatment, medical, insurance, or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. This consent form will not allow Mystic Dental Group to release any other information to these family members. I authorize/allow Mystic Dental Group to release my dental treatment or billing information to the following person(s).

Past Due Accounts: Account aging begins the day your charges are incurred. Accounts that are ninety days past due may be turned over to a third-party collection agency. Should it become necessary to place your account for Collections, and/or Small Claims Court, you shall be responsible to pay all costs thereof including, but not limited to, attorney fees.

You will be asked to leave your "estimated" cost-share at the time of service. THIS IS ONLY AN ESTIMATE. As a courtesy, we will submit your claim to your dental plan for processing. The insurance industry is every changing with varying exclusions and conditions to each policy. We cannot guarantee a payment will be made from your insurance plan.