Questionnaire Acknowledgement

Questionnaire Acknowledgement

Please Initial that you have read and understood the following
Medical History
I certify that the answers to the health questions are accurate and correct to the best of my knowledge. Since a change of medical condition or medications can affect dental treatment, I understand the importance of and agree to notify the dentist of any changes at a subsequent appointment.*
Consent for Communication
Due to the changing world of healthcare and technology, Smile365 Dental now has the ability to provide our patients with certain types of information via text messaging and email. I give consent to Smile365 Dental to contact me via text messaging and email for the purpose of health information and appointment reminders.*
Privacy and Sharing of Information
I authorize the collection of my personal, medical, and dental information including dental photography. I authorize the exchange of relevant information between Smile365 Dental and insurance companies, and other medical/ dental offices as deemed necessary.*
Cancellation Policy
Smile365 Dental is committed to providing all our patients with exceptional care. Please consider that your appointment has been reserved exclusively for you. When a patient cancels without giving two working days notice, it prevents another patient in need from being seen. In order to be respectful of the needs of other patients, please be courteous and call our office promptly if you are unable to attend an appointment. Notification of any changes must be given at least two business days prior to your scheduled appointment. If this notice is not given, there may be a fee for the missed appointment.*
Financial Policy
Smile365 Dental will do it’s best to estimate what my insurance plan will cover based on the limited information we receive. I understand that my insurance cannot or will not divulge specific reimbursement information to my dentist, as the contract for coverage is between me and my insurance carrier. Therefore, I acknowledge that the entire cost of my treatment is my responsibility regardless of insurance coverage. As a courtesy to me, Smile365 Dental will accept payments directly from my insurance, but I am responsible for any balance after such payments and any costs associated with the collection of the balance. *
Signature*
Name*

First NameLast Name
Date*

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