INFORMED CONSENT / GENERAL RELEASE
I the undersigned, certify that I have provided an accurate and complete personal and medical / dental history and have not knowingly omitted any information. I have had the opportunity to ask questions regarding my medical / dental history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for all fees associated with these services. I give this office consent to contact me via email or phone for appointments and newsletters.
In our continued commitment to provide the highest quality dental care to all of our patients and to make those services comfortably affordable, we are pleased to offer you these payment options. We will, as a courtesy, process your insurance benefits in our office, which will relieve you of this time consuming and sometimes complicated task. We are committed to support you in understanding your dental health, so that you will always be able to make the best choices.
I agree that I am fully responsible for the total payment of all procedures performed in this office - this includes any treatment that is not a benefit of any dental insurance that I may have.
Appointments times are reserved especially for you. lf you come in late, the Doctor may request that you reschedule the appointment and you may be charged a fee of $75. lf for any reason you should need to change your appointment, there will be no charge, provided you give us 2 business days’ notice. lf an appointment is cancelled with less than 48 hrs, a potential fee of $50 may be applied to your account. We are here to assist you in any way possible. Please make your questions and concerns know to our team. Our goal is to ensure that you have an outstanding experience.
HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENTS’ PERSONAL INFORMATION
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is collecting, using and disclosing your personal information.
This office will collect, use and disclose information about you for the following purposes:
- To assess your health needs and provide safe and efficient dental care.
- To enable us to contact and maintain communication with you to distribute healthcare information and to book and confirm appointments.
- To communicate with other treating health-care providers, including other dentists, physicians, pharmacists, and lab technicians.
- For teaching and demonstrating purposes on an anonymous basis.
- To complete and submit dental claims for third party adjudication and payment.
- To comply with legal and regulatory requirements.
- To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, as necessary.
- To invoice for goods and services.
- To process credit card payments.
- To collect unpaid accounts.
- Thank you for your support and understanding in helping our office to comply with all regulatory requirements, and generally with the law.
I have read and understand the Privacy Police Statement: