Patient Consent Form

TO OUR PATIENTS WHO HAVE DENTAL INSURANCE:

We are very pleased you chose our office to provide you with ongoing dental care. It is of the utmost importance to us that your oral health be the very best it can be.

Your insurance coverage is an arrangement between you and your insurance provider as well as your place of employment. There are numerous policies and forms of coverage which can range from 20% to 100%, dependent on the plan. As well as being on a previous years’ fee guide, called a “lag”. The amount of coverage you are provided with does not involve the dentist. Our staff however, would be more that happy to find out your insurance coverage breakdown, enabling you to make an informed decision about your dentistry. Your insurance carrier will forward the payment directly to our office with your portion(co-pay), deductibles being paid by you at the end of your visit. THE OUT OF POCKET PORTION(CO-PAY) OR TREATMENT NOT COVERED BY THE PLAN MUST BE PAID AFTER EACH APPOINTMENT

CANCELLATION POLICY

We have reserved a specific appointment time just for you. Please allow us the courtesy of two business days’ notice if you need to reschedule, failing to do so, a $50 non-refundable fee will be applied to your account. Thank you for your cooperation and understanding.

EMAIL/TEXT MESSAGING PROGRAM

We provide a confirmation and communication service to all our patients via texting or email. This includes appointment reminders, confirmation of appointment, request for appointments, satisfaction surveys as well as general communication. You may opt out of our communication system anytime. Please notify our admin team if you have any questions, or concerns.

PHOTOS and INTRA-ORAL PICTURES

By signing below, you agree to our office taking facial and intra-oral photos. These are for our office use ONLY and are used for patient identification and patient education. Please do not hesitate to discuss with our staff if you have any questions or concerns.

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.