Ridge View Dental | Minor Patient Information

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. In the event of non-payment for dental services received, the undersigned agrees to pay all lawyer fees, court costs, and collection fees up to 50%, if turned over to an outside collection agency.
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FINANCIAL AND INSURANCE POLICIES
Thank you for choosing us as your dental care provider. We are anxious to serve you and are committed to providing the best care possible. Payment is due at time of treatment. In order to make your dental care financially comfortable, we offer the following financial options:
Please select the option(s) that will be the most comfortable for you:*

Payment in Full Courtesy. A prepayment courtesy of 10% will be subtracted from the total patient obligation if the patient obligation is paid in full. We accept Cash, Visa, MasterCard, Discover, American Express, Money Order, Personal ChecksOutside Financing. Our office uses CareCredit® for flexible payment options. We have options ranging from 6 to 12 months interest free financing based on the amount of dentistry financed. Approval must be received prior to treatment dateNo Dental Insurance Discount (20% with the In-office Dental Plan). Patients without dental insurance will be given a 20% when they sign up for the Ridge View Dental Plan (ask for details). This offer cannot be combined with the “Payment in Full Courtesy” listed above.
INSURANCE POLICY

Insurance benefit coverage depends solely on what your employer wishes to purchase. The financial obligation for dental treatment is between you and our office. The insurance company is responsible to you, and not to our office. We will assist you in any way we can. Any amount owing after your insurance company has paid will be due from you upon receipt of our statement. If for any reason we have not received your insurance carrier’s payment 90 days after the claim was submitted, the remaining balance will be due and payable by you and subject to 18.5% APR. Should the account be referred to an attorney or collection agency, I will pay all cost of collection, including up to 30% collection fee, as well as court costs and a reasonable attorney fee.
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AUTHORIZATION FOR SIGNATURE ON FILE

I, hereby authorize Ridge View Dental to affix my name to any and all claims and documents as related to any and all health benefits due me and my dependents. To the extent permitted under applicable law, I authorize release of any information relating to the claim. I hereby authorize payment of health benefits, otherwise payable to me, directly to the office listed above. I agree to be responsible for all charges for services and materials not paid by my health benefit plan. A photocopy of this document may act as an original. I also authorize Ridge View Dental to contact my insurance company by email communications or me by text messaging regarding my appointments.
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ACKNOWLEDGEMENT OF RECEIPT OF OFFICE PRIVACY POLICY (HIPPA)

I have reviewed a copy of the Office’s Privacy Policies.
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LONG APPOINTMENT DEPOSITS

To provide the absolute best care to our patients, certain procedures take longer than others. Because of this, a deposit of either $100 or 10% of the total appointment value will be required to secure those types of appointments.
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CANCELLATION AND NO-SHOW POLICY

Due to the number of patients requiring treatment, Ridge View Dental is now implementing a fee for cancellations with less than 48 hours’ notice or if you do not show up for a scheduled appointment.
- General Dentist & Hygiene Appointments = $50.00/per hour
These fees will be posted to your patient ledger if you cancel an appointment within a 48-hour period or if you no-show your appointment.
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I also understand that Ridge View Dental will move my appointment(s) off the schedule after 3 attempts to confirm my appointment(s) without a returned call or confirmation from the patient or parent of the patient, if a minor.
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By signing below, I understand the Financial and Insurance Policies, Authorization for Signature on File, the Acknowledgement of Receipt of Office Privacy Policy, the Long Appointment Deposits, and the Cancellation and No-show Policy of Ridge View Dental and have had any and all questions answered to my satisfaction.
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(Parent or Guardian if Minor)
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CONSENT TO PROCEED
I authorize the doctor(s) of Ridge View Dental and such associates, or assistants as they might designate to perform those procedures as may be deemed necessary, or advisable to maintain my dental health, or the dental health of any minor, other individual for which I have responsibility. This includes arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or pharmaceutical agent(s), including those related to restorative, palliative, therapeutic, or surgical treatments.

I understand that the administration of local anesthetic may cause untoward reaction or side effects, which may include, but are not limited to: brushing, hematoma, cardiac stimulation, and temporary, or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval.

I understand that as a part of dental treatment, including preventative procedures such as cleaning and basic dentistry including filling of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. After lengthy appointment, jaw muscles may also be sore or tender. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or the oral tissue to be inadvertently abraded or lacerated during routine dental procedures. In some cases sutures or additional treatment may be required.

I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician, or hospital and may in rare cases, required bronchoscope, or other procedures to ensure the safe removal. I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past, such as Phen-fen. I understand that taking the class of drugs prescribed for the prevention of osteoporosis may result in complication of non-healing of the jaw bones following oral surgery.

I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results; which may or may not be achieved for my benefits, or the benefits of a minor or other individual responsible for. I acknowledge that the nature and purpose of the foregoing procedure have been explained to me if necessary and I have been given the opportunity to ask questions.
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(Patient, Legal guardian, or authorized agent of patient)
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