I also give my consent to ANY advisable and necessary dental procedures, medications or anesthetics to be administered
by the attending dentist or his supervised staff for diagnostic purposes of dental treatment. These records may include
study models, photographs, x-rays and blood studies. I understand and acknowledge that I am financially responsible
for the services provided for myself and or the above named, regardless of insurance coverage. Treatment plans
involving extended credit circumstances are subject to a credit check. I also understand that the treatment plan presented
to me is only an estimate. Occasionally, the need may arise to modify treatment. In such a case, I will be informed of
the need for additional treatment, and any fee modification.
To the best of my knowledge the information in this form is accurate.
Signature of Patient or Guardian
Signature of Witness
Signature of Doctor
As your time is valuable, we want to assure you that you will be seen on time for your appointment. Likewise, we would
appreciate a 24 hours notice should you every have to change an appointment, so that another patient in need may
receive care. We will make every effort to make your visit as pleasant and comfortable as possible.
I authorize the use of my radiographs and/or photographs for use in seminars or publication of Dr. Del Kovacevic.
Signature of Patient of Guardian of minor
In order to provide you with the highest quality dental care available, we provide our patients with estimates of dental
treatment and fees. Patient, parent and/or guardian are responsible for the patient portion at the time of service.
Financial options that we provide at this time:
Purpose of consent: By signing this form, I consent to the use and disclosure of my protected health
information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: I understand that I have certain rights to privacy regarding my protected
health information. These rights are given to me under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA).
I have been informed of and given the right to review and secure a copy of your Notice of Privacy Practices
which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from
time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and
disclosed to carry out treatment, payment and health care operations, but that you are not required to agree
to these requested restrictions. However, if you do agree, you are then bound to comply with this
Right to Revoke: I understand that I may revoke this consent, in writing, at any time. However, any use
or disclosure that occurred prior to the date I revoke this consent is not affected. I understand that you may
decline to treat me, or continue treatment, if I revoke this consent.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice
at any time by contacting the office.
I have had full opportunity to read and consider the contents of this Consent form and your Notice of
Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and
disclosure of my protected health information to carry out treatment, payment activities, and health care