WORK TO BE DONE: I understand that I am having the following work done:InitialsX-rays Exam Other
DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock.Initial
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. For example, root canal therapy following routine restorative procedures. Any changes will be informed to the patient before changing the treatment. Initials
Parents not accompanying their child to an appointment must make PRIOR arrangements for payment (cash, check or credit card authorization).
Parents accompanying their children are financially responsible for payment.
18% annual interest is charged for any unpaid balance. A $15 fee is charged for nonpayment.
There is a $30.00 processing charge for non-sufficient funds or returned checks.
Records can be viewed at any time. There is a nominal charge for release or copies of records.
I blanks agree to these financial terms.
When we make your appointment, we are reserving a room for your oral healthcare needs. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved time to another patient in need. As a courtesy, we will allow 1 excused broken appointment for legitimate emergencies.
There is a $50.00 charge for breaking your second unexcused appointment. Repeated cancellations or missed appointments thereafter will result in the indefinite dismissal from the practice.
We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you.
By signing this form, you will consent to our use and disclosure of your protected health information (PHI) for the following purposes:
I have received/been offered a copy of the above-named office's Notice of Privacy Practices (NOPP) containing a detailed description of the uses and disclosures of my PHI.
We reserve the right to change our privacy practices as described in our NOPP. If we change our privacy practices, we will issue a revised NOPP, which will contain the changes. Those changes may apply to any of your PHI that we maintain.
I understand that I have the right to revoke this consent at any time by giving us written notice of your revocation of this submitted to our office. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.
I have had full opportunity to read and consider the contents of this consent form and this office's NOPP. I understand that by signing this consent, I am giving my consent to your use and disclosure of my PHI to carry our treatment, payment activities, and health care operations.