Patient Information
Dental Insurance Information or Person Responsible for the Account
Secondary Dental Insurance Information
Dental Information
Medical Information
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered questions truthfully and to the best of my knowledge. I understand that it is my responsibility to advise your office of any changes in the information contained on this form.
Consent:
1. The undersigned hereby authorizes the doctor to take x-rays, study models, photographs, or any other
diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's dental needs.
2. I also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use
the appropriate medication and therapy indicated for such treatment in connection with
3. I hereby authorize payment directly to Dr. Michael Gabor of my dental benefits and to provide any insurance
company or health care professional with information concerning my treatment in order to evaluate and
administer claims. I understand that all responsibility for payment for dental services provided in this office
for myself or my dependents is mine, due and payable at the time services are rendered unless other
arrangements have been made. I also agree to pay all costs incurred for collection of overdue account. A
monthly finance charge of 1.5% (18% per year) shall be charged on all outstanding accounts after 30 days.
After 90 days delinquent the consumer will be responsible for paying a collection cost of 15% on account, per
applicable state law. A minimum charge of $40.00 will be added for any dishonored checks.
4. There will be a $50 charge for any appointments not kept without a 24-hour notice. Please keep in mind, this
charge is NOT covered by insurance.
The office of Dr. Michael Gabor and Dr. Soyna Kapoor does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.