Acknowledgement of Receipt of Notice of Privacy Practices

I have received a copy of this office’s Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For Office Use Only

Scheduling Policy

We know that your time is important. Therefore, we make every effort to see all of our appointed patients at their appointed time. We are able to do this by working efficiently and not overbooking our providers. When an appointment is scheduled, we reserve the room, equipment, materials and time needed to address your specific dental needs. In return, we ask that you keep all scheduled appointments.

Rescheduling:

If you must change an appointment, please notify our office by phone at least 48 hours prior to your scheduled appointment.

*Please note we cannot accept appointment changes via e-mail, text, or voicemail.

Reminders/Confirmations:

We will use texts, phone calls or e-mails to remind you of upcoming appointments. Please reply with a confirmation so that we know to expect you (a confirmation will stop additional reminders).

*If your phone number changes, please notify our office at your earliest convenience.

Longer Appointments:

When scheduling a longer appointment, you may be notified that a confirmation is required to keep the appointment reserved.

Broken Appointments:

A broken appointment is considered any scheduled appointment for which you failed to show or a scheduled appointment that was cancelled less than 24 hours prior to the appointed time.

*A fee of *75 per hour will be charged.

Multiple broken appointments will result is dismissal from the practice.

I have read and agreed to the above policy,

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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