Please understand that the amount for your treatment at each visit to Portland Smiles is the patient’s responsibility and that insurance is billed as a courtesy to assist you. Please know the quote for your treatment is an ESTIMATE and NOT a guarantee of payment by your insurance. If the insurance company pays more, you will receive a refund. If the insurance company pays less, you will receive a bill for the difference.

Thank you.

Financial Consent Form

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I have read and understand the above.*
Signature of Patient, Parent or Guardian*
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