Patient Signature:

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Please note that there will now be a $10 COVID-19 PPE (Personal Protective Equipment) Surcharge for all appointments.
Please kindly give 48 hours advanced notice if you cannot keep your appointment. There is a $50 fee per 60 min that will be charged to your account for the time reserved for appointments missed or cancelled without 48 hours advanced notice given. If you are late to an appointment, please understand that your appointment may be shortened or rescheduled.