[pic] Watergate Dental Associates
The Watergate: 2506 Virginia Avenue, N.W., Washington, D.C. 20037
(202) 965-5400 www.watergatedental.com

Financial Agreement

Patient’s Name: Date:

I hereby authorize Dr. Gluck at Watergate Dental Associates, to perform upon me the following procedure(s):

Dr. Gluck has fully explained to me the purpose of the procedure(s) and has also informed me of expected benefits and complications (from known or unknown causes), attendant discomforts and risks that may arise, as well as possible alternatives to the proposed treatment, including no treatment. The attendant risks of no treatment have also been discussed. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the procedure(s).

I understand that during the course of the procedure(s), unforeseen conditions may arise which necessitate procedures different from those contemplated. I, therefore, consent to the performance of additional procedure(s) which the above-named dentist may consider necessary.

The estimated fee for the above-listed procedure(s) is: $ , with my estimated portion being: $ . My estimated portion is due and payable at the next visit.

I understand that I am responsible for ALL fees regardless of insurance coverage. I also