Your dental appointment time is reserved especially for you. We require 2 business days notice if you are unable to keep a reserved appointment, otherwise it may be necessary to charge for time lost if insufficient notice is received. The fee will be determined by the dentist or hygienist you have been scheduled with. We understand and respect that your time is valuable as well, and will endeavor to see you at your reserved time.
Patient 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 and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services for myself and my dependants is mine, and I will assume responsibility for fees associated with these services.
Insurance Policy: I understand that the fees listed for dental treatment may not be covered by or may exceed my dental benefits. I understand that I am financially responsible to my dentist for the entire cost of treatment. I authorize the release of information regarding dental treatment to my Insuring Company/ Plan Administrator via manual claim forms and/ or electronic transmission. I authorise communication of and submission of information related to the coverage of services provided to the named dentist.
Payment is required at time of treatment. Payments may be made by VISA, MasterCard, Debit or Cash. Special financial arrangements may be made for major treatment costs. Speak with the office before treatment begins.