OFFICE CANCELLATION OFFICE
We require a 24HR notice for cancellation of appointments. There will be a $35 charge for missed appointment or cancellations less 24HRS in advance. This charge is not covered by insurance.
OFFICE FINANCIAL POLICY
All dental services performed must be paid for at the time the services are rendered, if the patient does not have dental insurance. Patients, who carry dental insurance, understand that dental procedures will be billed to the insurance company at the time they are performed, as a courtesy from our office. If you have insurance, it is basis &/or major services? Insurance benefits & treatment plans are only an estimate & are subject to change. This dental office cannot render services on the assumption that our charges will be paid in full by an insurance company. A finance charge of 1.5% per month will be imposed on all goods & services not paid for within 90 days. This an annual percentage of 18%. If collection is made by suit or otherwise, patient &/or responsible party agrees to pay interest until paid, collection costs of 33.3% of the remaining balance & all attorney fees & court costs. I grant permission to you or your assignee to phone me at home, on a mobile device or my workplace to discuss matters related to this form.
CONSENT TO PROCEED
I authorize Dr. Moore &/or such associates or assistant as he may designate, to perform those procedures as may be deemed necessary or advisable to maintain my dental health of any minor or other individuals for which I advisable to maintain my dental health or the dental health of any minor or other individuals for which I have a responsibility, including arrangement &/or administration of any sedative (Nitrous Oxide), analgesic, therapeutic &/or pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatment, I understand that administration of local anesthetic may cause an untoward reaction or side effects which may include, but are not limited to a bruising, hematoma, cardiac stimulation, muscle soreness & temporary or rarely permanent numbness. I understand that occasionally needles break & may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes & may require irritation. I understand that as part of the dental treatment, including preventative procedures such as cleanings & basic dentistry, including fillings of all types. Teeth may remain sensitive or even possibly quite painful during & after completion of treatment, Dental materials & medications may trigger an allergic &/or sensitive reaction.
After lengthy appointments, jaw muscles also be sore or tender. Holding one's mouth open, in a predisposed patient, can precipitate a TMJ disorder. Gums & surrounding tissues may also be sensitive &/or painful during &/or after treatment. Although rare, it is also possible for the tongue, cheek, or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required.
I understand that as part of dental treatment items including, but not limited to, crowns, small dental instruments, drill components, etc. may be aspired (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-ray to be taken by a physician or hospital & may, in rare cases, require bronchoscopy or other procedures to ensure safe removal.
I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past, such as Phen-Fen. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva, or Actonel, may result in complications of non-heading of the jawbones following oral surgery or tooth extractions. I do voluntarily assume any and & all possible risks, including the risk if substantial & serious harm, if any, which may be associated with general preventive & achieved, for my benefit of my minor child. I acknowledge that the nature & purpose of the foregoing procedures have been explained to me if necessary & I have been given the opportunity to ask questions.
Nitrous is available upon request. It is at an additional $69 which is NOT covered by most insurances, We also offer sedatives by Rx only, but they require someone to drive you to & from your dental appointments. Netflix in the operatories for your enjoyment.
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.