This office’s Notice of Privacy Practices can be found at DrBoch.com or a printed copy is available at the office by request. I acknowledge receipt of this Notice of Privacy Practices.
* You May Refuse to Sign This Acknowledgment*
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
Communications barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Please read the following and indicate consent.
I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
I understand that during the course of treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. I give my permission to the dentist to make any/all changes and additions as necessary after discussing the situaion and options with me.
I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable.