Cost: $ - Cost: $

Name:______________________________________ Name:______________________________________
Doctor:______________________________________ Doctor:______________________________________
Nurse:_______________________________________ Nurse:_______________________________________
Appointment Appointment
Reason:______________________________________ Reason:______________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
Another Appointment Booked: Yes No Another Appointment Booked: Yes No
Date:_______________________ Date:_______________________
If patient intends this agreement to cover services rendered If patient intends this agreement to cover services rendered
before the date it is signed (including, but not limited to before the date it is signed (including, but not limited to
emergency treatment) patient should initial below. Effective emergency treatment) patient should initial below. Effective
as of the date of first dental services as of the date of first dental services
Cost: $___.___ Cost: $___.___
Sign:_________________ Sign:_________________
Sign:_________________ Sign:_________________
Name:______________________________________ Name:______________________________________
Doctor:______________________________________ Doctor:______________________________________
Nurse:_______________________________________ Nurse:_______________________________________
Appointment Appointment
Reason:______________________________________ Reason:______________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
Another Appointment Booked: Yes No Another Appointment Booked: Yes No
Date:_______________________ Date:_______________________
If patient intends this agreement to cover services rendered If patient intends this agreement to cover services rendered
before the date it is signed (including, but not limited to before the date it is signed (including, but not limited to
emergency treatment) patient should initial below. Effective emergency treatment) patient should initial below. Effective
as of the date of first dental services as of the date of first dental services
Cost: $___.___ Cost: $___.___
Sign:_________________ Sign:_________________
Sign:_________________ Sign:_________________

Cost: $ - Cost: $

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