Patient Registration Form

Subscriber/Responsible Person

Failure to notify the office of an appointment cancelation less than 48 hours prior to your appointment can result in a broken appointment charge.
Method of Payment
Full payment for dental treatment provided is expected at the time of service. For your convenience, we accept cash, checks, Care Credit and all major credit cards. We are happy to file insurance for you. I authorize my insurance payment to go directly to RiverRock Dental. It is your responsibility to provide our office with the necessary information concerning your insurance. Understand that your insurance plan is a contract between you and your employer and the insurance carrier. Treatment plans are an estimate only. Any and all non-covered services will be billed directly to you. All financial arrangements must be made in advance. Past due accounts will result in 15% finance charge. If my account is turned over to collections for legal judgement or action, I am responsible for all attorney fees, court costs and associated cost with collections.
I understand that I am ultimately responsible for all costs of dental treatment. I grant the right to the dentist to release my dental history and other information about my dental treatment to third party payers.