I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.

I assign my dental benefits (if applicable) for dental claims submitted electronically by Winkler Dental Clinic and authorize payment directly to the Winkler Dental Clinic. This authorization shall continue in effect until the undersigned revoked the same. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for the remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on my dependents (if any).

The Winkler Dental Clinic requires 24 hours notice for any appointment changes or cancellations. We reserve the right to charge a fee of $87.90 in the event that this policy is not adhered to. The fee must be paid before any appointment will be rescheduled for yourself or any family member.

Our practice, and our respective contractors on our behalf, may utilize the contact information you have provided to us to send you information including appointment reminders, appointment scheduling and treatment reminders, and promotional messages about other services and products that we may offer.

By providing your contact information, including your cellular phone number below, you request and give express written consent to receive communications through text messages to your cellular phone number through the use of an automated telephone dialing system. You understand that the text messages you are agreeing to receive may include treatment reminders as well as promotional and telemarketing messages. The text messages are not encrypted (i.e., secure), which means it is possible that they could be accessed or viewed by others. Your consent means you agree to receive unsecure text messages and understand the risks. Message and data rates from your cellular carrier may apply for text messages.

You understand you may revoke your consent at any time, though that revocation will not apply to any text messages made in reliance of this consent before you revocation. You may reply [STOP] to stop receiving text messages in your cellular phone. Please let us know if you would like us to communicate with you by phone. You consent to receive communications by text message is not required in order to receive treatment or services offered by us, but it may enhance your experience. You further acknowledge that you may not consent on behalf of someone else or provide another person's cellular phone number. You represent that you give legal authority to provide consent.

You have the option of receiving communications from us via text messaging; or not at all.