EXAMINATION AND X-RAYS: I understand that the initial visit requires radiographs in order to complete the examination, diagnosis and treatment plan.

  1. DIAGNOSED TREATMENT : I understand that I may be having the following diagnosed: Circle
    a. Filling; Crown/Inlay/Onlay; Cleaning; Extraction; Root Canal Treated; Denture; X-ray; Other; Or no treatment needed.
  2. DRUGS, MEDICATIONS AND SEDATION : I have been informed and understand the antibiotics and analgesics amongst other medications may cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock.
  3. CHANGES IN TREATMENT PLAN :I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most coming being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary (server allergic reaction).
  4. CROWNS / ONLAYS / INLAYS / BRIDGES : I understand that sometimes it is not possible to match the color of the artificial teeth exactly to the natural teeth. I further understand that I may be wearing temporary crowns or fillings that may come off easily and that I must be careful to ensure that they are kept on until the permanent crown is delivered. I realize that the final opportunity to make changes to my restoration (including shape, size, fit and color) will be before cementation within 20 days from the preparation date. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown or bridge. I understand there will be additional charges for remakes due to the delaying permanent cementation.
  5. ENDODONTIC TREATEMENT (ROOT CANAL) : I realize there is no guarantee that root canal treatment will save my tooth; there are complications that may occur from the treatment; and that occasionally root canal filling materials may extend through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments; stresses vented in their manufacture can cause them to separate and break during use. I understand that sometimes additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand the root may be lost in spite of all the efforts to save it. Root called teeth must be covered by crowns or bridges.
  6. PERIODONTAL LOSS (TISSUE AND BONE) : I understand that I have a serious condition, causing gum inflammation, bone loss and it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacement and extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.
  7. PERIODONTAL CLEANING / SCALING : I understand that most common complications are pain, bleeding, tissue) gum) laceration, sensitivity to temperature or foods, swelling, ulceration (infection), tooth fracture and/or breaking of fillings. Reactions to fluoride treatment may be nausea or vomiting side effects on my periodontal condition.
  8. FILLINGS : I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage. I understand that sensitivity is common after effect of a newly placed filling.
  9. DENTURES AND PARCIALS : I understand that wearing of dentures or partials may be difficult. Sore spots, altered speech and difficulty eating are common problems. Immediate dentures (placed right after extractions of teeth) may be painful and immediate dentures may require considerable adjustments and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that this is my responsibility to return for delivery of dentures. I understand that failure to keep my delivery appointment may result in poorly fitting dentures or partials. If a remake is required due to my delay of more than 30 days, there will additional charge.
I hereby authorize any of the doctors at this facility and dental auxiliaries to proceed with and perform the dental procedures and treatments as had been explained to me. I understand this is only an estimate and subject to modification depending on foreseen or non-diagnosable circumstances that may arise during the course of treatment. I understand that regardless of any insurance coverage I may have, I am responsible for payment of dental fees. I agree to pay any attorney fees, collection fees and/or court fees that may be incurred to satisfy obligation.

HIPPA Acknowledgement

I grant my permission to the dental practice to upload and store confidential patient information (including accountant information, appointment information and clinical information) to the secured website for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered because of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security reasons.


Appointment Policy

24 hours’ notice is required to reschedule or cancel your appointment. Your appointment time is reserved for you, to accommodate all of our patients; we need sufficient time to schedule other patients waiting to be seen. Patients may be billed a fee for missing an appointment without sufficient advance notice (minimum fee $50.00). By signing below, I acknowledge that I have read and understand this new appointment policy. If you have any questions regarding our appointment policy, please ask us. We are committed to providing you with the most positive experience in dental and medical care.

Financial Policy

This statement is to inform you of our financial policy. We are committed to providing you with the highest quality of medical and dental care. Our financial policy is intended to facilitate excellent service to you while minimizing our administrative costs. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, now with your insurance company. Our office is not a part of that contract.

As a courtesy to you we will help you process all insurance claims. You may direct your insurance company to pay your benefits directly to our office by signing the authorization of Benefits Agreement. Co-payments are due at the time of the service provided. Our office accepts cash, personal checks, and major credit cards. Return checks and balances older than 60 days may subject to collection fees. If you have any questions regarding our financial policy, please ask us.

Notice to Insurance Patients

I am responsible for my balance if any of the following occurs:

  • The treatment goes over my yearly maximum.
  • Any treatment is denied by my insurance company.
  • I am not eligible for insurance.
  • I prevent or delay payment by not complying with request for insurance forms or signatures.
  • I do not complete my treatment and it results in non-payment by the insurance company.
  • Lab costs are incurred due to missing appointments.
  • I receive my insurance check and do not send it to your dental office.
I hereby authorize payment directly to the above-mentioned dentist of the group insurance benefits otherwise payable to me, but not to exceed the charges shown above. I understand that I am financially responsible for any charges not covered by this authorization. I hereby accept the foregoing treatment plan and authorize release of any information relating to this claim.

I have read and understand my obligations in acceptance of my dental insurance payment.