I certify that all of the preceding answers are correct. If I have any changes to my health status ormedications, I will inform the dentist and staff at my next appointment.
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.
I consent to treatment as necessary or desirable for the care of the patient first namedon the front of this form. This authorization provides for the utilization of procedures necessaryfor the diagnosis and treatment of dental disease, deformity, and dental emergency. Theseprocedures may include (and not be limited to) intraoral and extraoral examinations, radiographs,dental casts and photographs. I give my consent to the use of local anesthetics for pain reliefduring treatment and understand that the practice of dentistry involves the responses of livingtissues and a perfect result cannot be guaranteed.
I authorize the utilization and transfer (including electronic) of my photographs and dentalrecords to doctors, dental laboratory technicians, students and patients for the benefit oftreatment and education.
In the case of dental emergency, I consent to treatment as deemed necessary by theDoctor for myself and/or my child, understanding that the procedures will be explained inadvance if I am available and conscious. If I am not available or conscious I authorize the Doctorto provide emergency treatment for me and my family as deemed appropriate by the Doctor.
I grant the Conifer Dental Group the right to release my dental and medical treatmenthistories and other information to third party payers and/or other health professionals.
I acknowledge full responsibility for the payment of services and agree to pay for them,in full, at the time of service, unless other arrangements are made in advance. To avoid a misun-derstanding regarding dental insurance, all professional services rendered are charged directlyto the patient and patients are personally responsible for payment of fees. We will prepare neces-sary forms or reports to help you obtain insurance benefits upon receipt of payment of fees.
We do not render services on the basis that insurance companies will pay all fees.
I understand SERVICE CHARGES will be applied to any unpaid balances incurred by my family and me at a periodic rate of 1.5% per month even if they are subject to payment byinsurance companies. In the case of default of payment, | promise to pay any legal interest onthe balance due, together with any collection costs and reasonable attorneys fees incurred in thecollection of the account.
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.
To the best of my knowledge, all of the preceding answers are true and correct.
Please help us to update our records. We are trying to identify our patients’potential risk for diabetes and the possibility of having sleep apnea. Please answer the following questions.
I agree that the dental practice may communicate with me electronically at the email address above. I am aware that there is some level of riskthat third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address. |can withdraw my consent to electronic communications by calling 303-838-7904.
We take our patients’ care very seriously and want to ensure that we can offer appointments to our patients in a timely manner. When patients cancel or reschedule at the last minute those available time slots often remain unfilled, If we receive appropriate notice of cancellation, we can then offer those time slats to another patient in need of our dental care that has to wait to be seen.
Office Visits- Please arrive at least 5 minutes prior to your scheduled appointment time. Our Front Desk will check on you and update any changes to your insurance or contact information. If you are a new patient, please bring your completed paperwork with you or arrive 15 minutes prior to your appointment. If you arrive late to your appointment, you may be asked to reschedule in consideration of those who have arrived on time and are waiting to see one of the providers. You must cancel or reschedule your office visit appointment 24 hours prior to your appointment or you will be assessed a $50.00 fee. No-shows-Reschedules- If you continuously no-show your appointments or repeatedly reschedule, you may be dismissed from the practice. After three occurrences, your account will be reviewed by your Provider and a determination will be made.
1. I knowingly and willingly consent to dental treatment at Conifer Dental Group by Dr. Wilson and any designated associates and employees during the COVID-19 pandemic.
2. I understand that the Conifer Dental Group and Dr. Wilson are following CDC guidelines.
3. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still
highly contagious. It is impossible to determine who has it and who does not given the current limitations and availability in COVID-19 viral testing.I understand that dental procedures create aerosol (water spray) which is one way the disease is spread. The ultra-fine nature of the spray maylinger in the air for hours, which may transmit the COVID-19 virus.
4. Risk of transmission: | understand that due to the frequency of visits, of other dental patients, characteristics of the virus, and the characteristics of dental procedures, I have an elevated risk of contracting the virus simply by being in a dental office, even though mandates are being observed.
5. l am unaware of being a possible carrier or infected: I confirm that | have not tested positive for COVID-19 in the last 30 days and that | am not presenting with any of the following symptoms of COVID-19: Fever of 100.0 degrees F, Shortness of breath, Dry cough, Reduced sense of taste/smell, Sore throat, Runny nose.
6. Contact with infected: I confirm that I have not knowingly been in close contact defined as 6 feet or less for a duration of fifteen minutes or more with someone who has tested positive for COVID-19 in the last 14 days, or with anyone who has had the above-stated symptoms in the last 14 days.
7. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveleddomestically by commercial airline, bus, or train within the last 14 days.
INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures.
I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic.
I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and I have been given the opportunity to ask questions.
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