Insurance and Appointment Agreement First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY (Required) 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(Required) (Required) 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(Required) (Required) 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(Required) (Required) 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(Required) (Required) 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(Required) Card type(Required) Card #(Required) Expiration(Required) Cvv(Required) Date(Required) (Required) I have read and understand the above agreement.Signature(Required)CAPTCHA