Aesthetics & Prosthodontics Dentistry, LLC
849 Lincoln Avenue
Glen Rock, NJ 07452

Dental Insurance



The undersigned hereby authorizes the Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. Furthermore, I am aware of the 24 hour cancellation policy and understand that any missed or canceled appointments without ample notice will incur a reserved time fee. In the event my account is referred to a collection agency or attorney I will be responsible for any reasonable collection fees and/or legal fees.