Diagnosis is the key to any successful treatment. As you are presenting with no craniofacial or sleep disorders of which you are aware, our records appointment will be "limited" to the following records. If it is determined that there are underlying disorders and/or conditions beyond which the "limited" records will allow us to see, other records/tests may be indicated and recommended.

a)	CONSULTATION appointment (to meet Dr. Azouz and ask specific questions) fee will be assessed (30 minutes).

b)	Records Appointment

PROCEDURE	ADA CODE
Comprehensive Exam:	0150
FMX:	0210
Limited X-rays :	0274
Oral Cancer Screening:	0431
3D Cone Beam/CT (if needed)

Payment of Fees: If you have dental insurance, some of these fees may be reimbursable. Regardless of insurance coverage, however, payment for services rendered are due at the time of service. As a courtesy, you will be given a superbill at the end of your appointment. You may send this to your insurance company for direct reimbursement.

*	I attest that I understand and agree to the above-listed procedures and associated fees.