1. I authorize taking images (x-rays or photos) of my teeth and face.
2. I authorize using those images as "before and after" examples for other patients to see.
3. I authorize this dental office to call me either at work or at home regarding appointment confirmation.
4. I authorize the use of e-mail, voicemail, postcards, or messages to my home or work for appointment confirmation and information regarding patient services.
5. I understand for all major procedures that need to be performed, I will need to pay for the procedure before I will be given an appointment.
6. I understand my payment options for pre-payment are half paid at time of booking appointment with the other half due day of appointment, or payment in full with payments of cash or check over $5000.00 receiving a 3% discount.
7. I understand that if I pre-pay for an appointment, and do not show or cancel a 10% fee will be assessed out of the payment I have made with the remainder left as credit balance towards future treatment.
8. I understand Dr. Lan-Tu Holem's office will not release my records until my account has been paid in full and a release of records form must be completed.

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account. I have read all the information above. I will notify you of any changes in my status or any of my insurance information.

By typing my full name below, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.