HIPPA CONSENT

Patient Name Email Address City    State    Zip  Home Phone () Work Phone () Cell Phone () HIPPA Privacy Statement , Insurance and Dental Release By typing my name in the signature box below, I have been provided a copy of Overton Center for Dental Arts P.C. Privacy Statement to read. If I would like a copy of the policy I may request a copy today or any time in the future by stopping the office during normal business hours. Signature By typing my name in the signature box below, I hereby authorize Overton Center for Dental Arts P.C. to furnish my insurance company copies of my x-rays and records of my chart if requested for reimbursement. I understand I am financially responsible to Overton Center for Dental Arts P.C. for all charges, including those not covered by my insurance. Signature

At Overton Center of Dental Arts, P.C., though our focus is on appearance-related dentistry, we deliver full-service dentistry as well. With flexible payment plans as well as phasing treatment over time, you can achieve spectacular long-term results. Thank you so much for the opportunity to be of service.

Health and Happiness,
Dr. Tom Overton and Team