This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancertreatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19.

Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus in the past or currently.
 

UPDATE YOUR HEALTH HISTORY WITH US

If your health history changed since the last time you visited our office or you have not updated your health history with us for a year or longer, please fill out our Health History form, and submit it online prior to coming to your appointment.

 

ACKNOWLEDGEMENT

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to Richmond Family Dentistry any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

FULL PAYMENT

Richmond Family Dentistry has a full payment policy. This means that full payment is required at the time of service for major services and specialized cleanings. We accept cash, check, or credit card.

INSURANCE FILING

While the filing of insurance claims is a courtesy that we extend to our patients, all charges for our services rendered are your responsibility. We are not a party to your insurance company’s contract and it is your responsibility to contact your insurance company in case you have questions regarding the insurance coverage of our services.

MITIGATING CIRCUMSTANCES

If special circumstances make immediate payment impossible, payment arrangements must be approved in advance by our business office staff.

UNPAID BILLS

Bills unpaid for more than 30 days may be turned over to a collection agency or an attorney at the sole discretion of Richmond Family Dentistry unless other arrangements have been made with us. Accounts that are turned over to collections or an attorney for collection may result in dismissal from the practice. If the account is turned over to the collection agency or an attorney for collection, the account will be charged and you agree to be responsible for collection fees and/or attorneys’ fees of the greater of 33 1/3 % of the total amount owed or the attorneys’ of $300.00 per hour at the sole election of Richmond Family Dentistry. Carrying charges of 1.5% per month will apply to any balance more than 30 days past due.

DEPOSITS (NONREFUNDABLE) , CANCELATIONS & RESCHEDULING  OF TREATMENT APPOINTMENTS

Our office requires a deposit to be made in order to reserve a treatment appointment with Dr. Hart for 1 hour or longer. The deposit is 50% of the scheduled treatment cost. If you cancel your appointment for any reason and at any time, you forfeit your deposit.

Treatment reservations with Dr. Hart must be canceled by speaking with the front desk. Voicemails, emails, and text messages are not accepted as cancellations.

You have up to 72 hours prior to your scheduled appointment to reschedule it for the earliest available time slot by speaking with the front desk (voicemails, emails, and text messages are not accepted as rescheduled appointments). If the request to reschedule a treatment appointment comes within those 72 hours, you will be required to pay an additional non-refundable deposit to make the new treatment appointment.

MISSED/ CANCELED APPOINTMENTS FOR HYGIENE

Hygiene reservations with Christine must be canceled by speaking with the front desk ( voicemails, emails and text messages are not accepted as cancellations) at least 3 business days prior to the scheduled appointment.  Not doing this will result in an operatory reservation fee of up to $250.00.

DISMISSAL OPTION FOR MISSED APPOINTMENTS

Please help us serve you better by keeping all scheduled appointments. Multiple missed appointments may result in dismissal from the practice.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT​

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information.

I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third- party payers.
• Conduct normal healthcare operations such as quality assessments and physician qualifications. 

I understand that I might request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operation. I also understand you are not required to agree to my requested restrictions, but if you do agree and do so in writing then you are bound to abide by such restrictions.

PERMISSION TO DISCUSS DENTAL TREATMENT

In the event that you may want a family member or friend to discuss your dental treatment with our office, we must have in writing permission/consent to do so. Please list any person that you give Richmond Family Dentistry permission/consent to discuss your dental treatment with.

*If the patient is a minor, we will discuss dental treatment with either parent or guardian.*

Cone Beam Computed Tomography – CBCT

Acknowledgment and Informed Consent

Cone-beam computed tomography is a 3D dental imaging technique consisting of x-ray computed tomography where the x-rays are divergent, forming a cone. A CBCT is required in treatment planning and diagnosis.

The CBCT image is too large of a file to transfer electronically, therefore it must be copied onto a CD.

I understand I am entitled to one copy of this image on a CD that I agree to pick up from the Richmond Family Dentistry office. Additional copies or requests to mail CD with images are $25 each.