Dear Responsible Party,

We are delighted you chose our practice to provide your child's dental care. Our goal is to provide the highest level of care in a friendly and courteous manner. The Doctor/Patient relationship is a mutually beneficial relationship and requires the commitment of both parties. In order for our practice to provide your child with the appropriate dental care, we need you commitment to our policies. PLEASE READ AND INITIAL EACH POLICY:

1. If you have private dental insurance, please provide the front office staff with your card so that your benefits can be obtained. Please keep in mind that dental insurance is a CONTRACT BETWEEN YOU AND THE INSURANCE COMPANY. As a courtesy, we will file insurance claims for you. We cannot guarantee coverage for any treatment. ALL co-payments, deductibles and fees for non-covered services are to be paid at the time of service.

2. BROKEN APPOINTMENTS ARE NOT ACCEPTABLE. Your appointment with the doctor is a time set aside specifically for you and your child. If you need to change an appointment, we require a 24 HOUR NOTICE. Failure to provide us with a 24 hour notice will be considered a broken appointment. FAILURE TO SHOW FOR A SCHEDULED APPOINTMENT WILL RESULT IN A $25.00 BROKEN APPOINTMENT FEE. Because of the hardship it places on our practice, repeated broken appointments will result in termination of our doctor/patient relationship.

3. We reserve specific appointment times in our schedule for your child. It is your responsibility to remember your child's appointment and arrive on time. In order for us to properly utilize the time we have set aside for your child and out of respect for those patients who arrive on time, LATE ARRIVALS ARE SUBJECT TO BEING RESCHEDULED. If there is an emergency that prevents you from arriving on time, please notify our office as soon as possible so that we may adjust our schedule to accommodate you.

4. Following each examination, you will receive a treatment plan consisting of the necessary dental treatment for your child and the ESTIMATED cost. The treatment recommendations are made according to acceptable standards of care and what the doctor feels is in your child's best interest. You are encouraged to ask questions and be involved in the decision making when it comes to your child's treatment. Once we have agreed on a plan of treatment, we ask that you have the recommended treatment done in a timely fashion to in order to prevent a more serious problems from occurring. FAILURE TO FOLLOW THROUGH WITH TREATMENT AND PREVENTATIVE CARE CAN RESULT IN YOUR CHILD EXPERIENCING MORE SERIOUS AND COMPLICATED DENTAL PROBLEMS.

5. We encourage parents to accompany their child during all appointments. HOWEVER, OUR DOCTORS MUST HAVE YOUR CHILD'S FULL ATTENTION AT ALL TIMES. The doctor and child must be free from all distractions Therefore, we ask that if a parent wants to remain with their child during any treatment, that the parent is a "silent partner" during treatment. If being a "silent partner" is difficult, the doctor asks that you remain in the waiting room. In the event the doctor feels the parent is needed during treatment, the parent will be invited to the treatment room.

6. In order to keep your child's dental record current and accurate, we ask that you notify our front desk staff of any changes in address, phone number, insurance information and medical history as soon as possible.

7. We accept a variety of payment methods such as cash, personal check, money order, and credit/debit card. WE REQUIRE FEES TO BE PAID AT THE TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. If your account becomes delinquent due to unpaid balances, we reserve the right to seek remedy by any means available to us. If this procedure becomes necessary, you accept financial responsibility for any fees/charges encountered when attempting to collect on a delinquent account.

We look forward to a long lasting, caring, and professional relationship with you and your child. If you have any questions or concerns regarding the office policies please feel free to address them. By signing below you accept our office policies.