Authorize Bowen Legacy Dental to take photographs and/or videos of my face, jaws and teeth, before during and after treatment.

I consent to allow the photographs to be used for the following:

I further understand that, including websites and printed material, patient education and social media posts, such use may include demonstrations and discussion.

OR

We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that the payment of your bill is considered part of your treatment.

We are a fee for service practice and collect in full at the time of service. If you have insurance, you will pay in full at the time of service and your insurance will reimburse you directly. We are committed to making decisions for each patient based on what is best for your oral health.

As a courtesy to you, we are happy to file your dental claim on your behalf. Please note that Dr. Bowen is an in-network provider with Delta Dental Premier and Dr. Gehlert is not an in-network provider with any insurance companies.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company.

I have read, understand and agree to the above terms and conditions.

*You may refuse to sign this acknowledgement*

HIPAA Release of Information

This release of information will remain in effect until terminated by me in writing.

Messages

If unable to reach me:

I understand that dental oxygen/ozone therapy involves the injection of a mixture of oxygen and ozone in the form of a gas with or without local anesthetic. The injection can be given in the skin, mucous membranes, muscles, joints, jawbones, teeth, neck and/or other associated structures.

I understand that prior to any treatment involving injections with anesthetics I should tell the doctor or staff if I have ever experienced an allergic reaction to any anesthetic, particularly dental anesthetics.

Dental oxygen/ozone therapy carries with it some risk of side effects such as pain and/or discomfort at the injection site, soreness and temporary bruising. The most common side effect is a warm or burning sensation at the site of the injection or flu-like symptoms for 2-3 days following treatment.