I hereby authorize Dr. Ross Epstein and his staff to take X-rays, study models, photographs and all other necessary diagnostic aids required to formulate and perform a complete and comprehensive treatment plan. I also agree to comply with the doctor's decision on a systematic order of treatment accoring to the priority system of standard care. I also give my permission to Dr. Epstein and his staff, in the course of treatment, to consult any and all persons necessary to complete my dental care in a timely and responsible manner. I also agree to a 1.5% monthly interest rate on all delinquent accounts over 30 days, except where previous arrangements have been made. I understand that insurance is not a guarantee of payment and I am responsible for all fees not covered by insurance. I take full responsibility for all late payments made after 60 days by insurance companies. In the event of a divorce or separation, I agree to complete the payments for all outstanding bills that remail. I am also responsible for all fees charged by collection agencies and lawyers in pursuit of delinquent accounts. I understand that a minimal fee applies to all failed or cancelled appointments without 24 hours prior notice. All the above information is true and I understand and agree to all of the above policies as set forth by Dr. Ross Epstein.