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Southwest Portland Dentists
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1Contact Information
2Financial Information
3Dental Release Information
4Signature: Your rights and permissions

  • Minor Child - May need to complete both blocks for parent information

    Adults - Complete primary insured

    Duel Coverage? Also complete secondary insured
  • Dental Insurance 1st Coverage

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  • Dental Insurance 2nd Coverage (if different then primary)

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  • Authorization

    • I hereby authorize payment directly to South Waterfront Dental of the group insurance benefits otherwise payable to me.
    • I understand that I am responsible for all costs of dental treatment. I hereby authorize South Waterfront Dental to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care.
    • The information on this page and the dental/medical histories are correct to the best of my knowledge.
  • Consent

  • Financial Agreement & Cancellation Policy

    • In order to assist you in making payments for your dental treatment, several options are available. Payments may be made by cash, check, credit card (VISA, MasterCard or Discover) or Care Credit. We reserve the right to charge a $25.00 fee for all checks returned for non-sufficient funds. Unless other arrangements have been made, your balance is due at the time services are rendered.
    • If you have dental insurance, as a courtesy, we will bill your insurance carrier directly. Dental insurance rarely covers 100% of services rendered; therefore please be prepared to pay your co-pay at each visit. South Waterfront Dental is happy to provide an estimate for your co-pay prior to your visit. This is an estimate only and you will be responsible for any amounts not reimbursed by your dental insurance.
    • Scheduled appointments are reserved specifically for you. If you need to change an appointment, please contact the office with at least 48 hours notice. There will be a $25.00 fee for appointments cancelled without 48 hour notice. There will be a $50.00 fee for not showing for a scheduled appointment.
    • We realize that time is very important to you, and we make every effort to stay prompt. We ask that you have the same consideration by being on time for your appointments.
    • Please do not hesitate to ask any questions you may have concerning office policies. We welcome open communication with you and wish to develop a relationship of friendship and trust. Our goal is to meet your dental needs while offering you the most comfortable and enjoyable dental experience.
  • By typing your full name here, you are electronically signing this document.
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OUR LOCATION

3580 S River Pkwy
Portland, OR 97239
Phone: (503) 841-5658
info@southwaterfrontdental.com

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