Dr. Robb Heinrich | North Spokane Dentist - Patient Form

Payment is due in full at time of treatment, unless prior arrangements have been approved. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnoses and records of treatment to my insurance company.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I also give permission to Dr. Robb Heinrich and his staff to use any photos take for lecturing and continuing education purposes.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.