I certify that the above is true

The services rendered by Dr. L. Scott Brooksby are provided only on the basis of payment in full at the time of service. 

Payment at each visit may be made in any one of the following manners: Cash, VISA, MasterCard, Care Credit, Discover Card or personal check (with a guarantee card and valid driver’s license.)

In the event of default of any kind on these financial obligations, the patient and responsible party will be liable for all costs, including interest at the rate of 1.5% (18% APR), a monthly service charge of $5.00 per month, collection costs, attorney’s fees and court costs incurred to collect said funds.

This office complies with all HIPAA requirements regarding the privacy of your documents. Transfer of your documents will always require your prior authorization.

Tele-dentistry

On an as needed basis, Dr. Brooksby may provide care via telephone or video. This may include establishing an initial Dentist-patient relationship to treat a toothache. It is understood that there are definite limitations to the ability to diagnose an infection. It is agreed that we are establishing a Dr.-patient relationship and accept all limitations to this type of care. I agree to pay via credit card or Zelle for these services and will not contest these charges. I also agree that this may limit the privacy protections of HIPPA and waive these protections.

During treatment, photographs and models may be made to document treatment or use in professional journals, lectures, or as examples of treatment for other patients.

Our fees generally are as follows:

Emergency examination -- $75.00

Single X-ray -- $25.00

Additional X-ray -- $22.00

Full Mouth X-ray series -- $130.00

Infection control -- $5.00

teledentistry fee of $100.00

All fees will be discussed with you in advance.

I understand that Dr. Brooksby does not accept assignment of benefits from my insurance carrier, and that I am responsible to pay the entire amount as services are rendered. Dr. Brooksby will try and bill my insurance company with the information that I provide. I understand that if that information is incorrect in any way that I will not hold Dr. Brooksby or his staff responsible.

In the event that there is a dispute about the care provided, I agree to binding arbitration.

I accept the above provisions and request Dr. Brooksby’s services

Signature of patient or responsible party