Insurance and Appointment Agreement "*" indicates required fields First Name*Last Name*Date of Birth* MM slash DD slash YYYY * I wish to assign my dental benefits to Singer Dental and I understand that any amounts that are not covered by my benefits are my sole responsibility. I may alternatively select to pay for my treatment directly and have benefits assigned directly to me.Initial here** I acknowledge my care provider (Dentists and Hygienists) at Singer Dental may recommend treatment for my dental health that is not a covered benefit under the specific plan selected by my employer. I will advise when booking valuable chair time if I intend to decline recommended services.Initial here** I acknowledge that my benefit co-pay (the amount I pay) at the time of booking or at the appointment is an estimate only. I may have a remaining balance to settle personally after my benefit provider processes payment, or I may have a credit to apply to future treatment.Initial here** I acknowledge that in order to avoid a cancellation fee or forfeit my booking fee, I will provide two working days’ notice if an appointment time is no longer feasible. If my personal or work schedule is unpredictable, I will be provided with Same Day Privilege booking options.Initial here** I am providing my credit card information below, and I authorize Singer Dental to charge any outstanding balance that I have on my account.Initial here*Card type*Card #*Expiration*Cvv*Date** I have read and understand the above agreement.Signature*Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*
