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Dental Care & Wellness of Sonoma County


  Last name

  Mid name

  First name

Notice of Privacy Practice
* I acknowledge that I have read/and received your Notice of Privacy Practices containing a complete description of the uses and disclosures of my health information from Jurina Smida D.D.S
* I also acknowledge I have read/received the Dental Material Face Sheet Dated October 2001 from Jurina Smida D.D.S.
* The undersigned hereby authorizes the Doctor to take X-rays, study models, photographs or any other diagnostic aids, deemed appropriate by Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time service is rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. I further understand that a late charge will be added to any overdue balance.
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)