To our patients: Although dentists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Please check the appropriate box or boxes to indicate if you have ever had any of the following conditions.
I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Payment or Copayment is due at time of services
* We accept all major debit and credit cards, along with cash and checks.
* We offer financing through Clearwater Credit Union.
There is a finance charge of 18% on all accounts over 90 days due.
If this account is not paid when due, and Jensen Dental should retain an attorney or collection agency for collection, I agree to pay all costs of collection including reasonable interest, reasonable attorney's fees (whether or not a lawsuit is filed) and reasonable collection agency fees in the amount of 50% of the balance due.
If it is necessary to cancel your scheduled appointment, we require that you call one working day in advance.
Same Day Appointment Cancelallation/Reschedule Fee Hygiene $40
Same Day Appointment Cancelallation/Reschedule Fee Dr. Jensen 1 hour $75
2 or more hours $150 and up (depending on time scheduled)