• The dental treatment recommended has been thoroughly discussed. I am aware some changes in the treatment plan may become necessary during the course of treatment, and that, if this is the case, these changes will be explained prior to the time they occur. The nature and purpose of the treatment listed in the treatment plan and any possible risks involved have been fully explained.

• I will pay in full any cost outlined in attached quote . I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for any costs that my insurance does not cover.

• I am welcome to ask questions about any aspects of the treatment plan and will request information if I am confused or need more information. I am responsible for clarifying any aspects of the treatment that I am unsure about.