EMERGENCY CONTRACT (Specify someone who does not live in your household)
DENTAL INSURANCE INFORMATION
NOTICE OF PRIVACY PRACTICES
- 1. The right to inspect and copy your information;
- 2. The right to request corrections to your information;
- 3. The right to request that your information be restricted;
- 4. The right to request confidential communications;
- 5. The right to report of disclosures of your information; and
- 6. The right to a paper copy of this Notice.
Acknowledgement of Notice of Privacy Practice
- In order to be respectful of the medical needs of other patients, please be courteous and call the office promptly if you are
unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. If it is necessary
to cancel your scheduled appointment, we require that you call at least 48 hours in advance. Calling early in the day is
appreciated. Appointments are in high demand, and your early cancellation will give another person the possibility to have
access to timely medical care.
- A failure to show up at the time of a scheduled appointment will be recorded in the patient's chart as a "no-show". There will
be a fee of $25.00 for regular appointments and $50.00 for any dental cleanings or surgerys. Late cancellations will be
considered as a "no-show". Exceptions will only be made in extraordinary circumstances. Cancellations made more than 24
hours in advance of your scheduled appointment time will not be assessed a cancellation fee.
- Please be sure to arrive at least 15 minutes early
- In consideration of other patients if you arrive more than 5 minutes late for your or your child’s appointment you may be
asked to reschedule.
Authorization For Use Or Disclosure Of Patient
Photographic and/or Video Images