I give permission to share my information with:

If consent is not granted to an individual, we will automatically deny information sharing to protect your records.

We ask for your consideration and cooperation in scheduling your appointments. We are partners in your dental care and we are committed to offering you appropriate care. Please understand that when canceling or rescheduling your appointment without sufficient notice, we miss the opportunity to fill that appointment time. This will result in missed opportunities to provide dental care for others. It is mutually understood that if a cancellation is due to circumstances beyond any control, such as unfortunate incidence or unsafe weather conditions, these emergencies will be considered on an individual basis. As a courtesy, our office confirms appointments two days in advance either by a phone call or text messaging.

Cancelation Policy

Confirming your appointment is your responsibility. We must have confirmation from you no later than 12pm the business day before your appointment. 

If we do not receive confirmation from you, your appointment will be released to accommodate other patients’ urgent dental needs and your appointment will be moved to the walk in and wait column for that day. If you are unable to contact us during business hours, please leave a message and we will get back to you. Thank you for supporting our cancellation policy.                                                                                                                                                                          

Failure to confirm your appointment, cancel or reschedule by the end of the previous business day, or a no-show on two (2) occasions will result in a walk-in-only status on your account. Patients with walk-in-only status must arrive and wait to be seen based on schedule availability for the remainder of the calendar year. Walk-in-only status resets at the start of each calendar year (January 1).       

Check In

ALL PATIENTS must be checked in, present, and have completed all forms by their appointment time. If a patient is not ready by their appointment time, they may wait as a walk in, or will have to reschedule. Arriving late does not give enough time for a full assessment. We require both a government Photo ID and insurance card at the time of appointment. For all children 17 and younger we require a parent/guardian government issued Photo ID. We will not be able to provide services to you if it is not available.

Child Supervision 

Children 17 and under must be accompanied by a parent or guardian at all times within the treatment area. Only the child receiving treatment may enter the treatment area unless contained in a stroller or equivalent. Children remaining in the waiting area must be under the supervision of a qualified adult. Failure to adhere to any of the above where a child is not adequately supervised may necessitate termination of treatment and rescheduling of dental procedure(s). 

Assignment of Benefits

I hereby request payment of authorized benefits to be made directly to Clear Lakes Dental for the services provided to me at this facility or any other facility owned and operated by Clear Lakes Dental.

Release of Records 

I authorize Clear Lakes Dental to release my dental records, including but not limited to diagnoses, X-rays, and information related to my dental health and treatment, to my insurance company and to verified dental clinics for purposes of treatment, referral, or coordination of care. I also authorize Clear Lakes Dental to provide referrals and X-rays directly to me during my visit or at the time care is being provided, once my identity has been verified. I understand that, in accordance with HIPAA privacy regulations, a separate, completed Release of Records (ROR) form is required for: Any patient-initiated requests for copies of records or X-rays made after I have left the clinic, Requests for additional records not listed above, or Authorization to release my records to any third party not specified above.

Payment of Account 
I acknowledge and understand that I am responsible for all charges for services rendered to me. Further, I clearly understand that it is my responsibility to make sure that the bill is paid in a reasonable amount of time. If, for any reason, any portion of my bill is not paid by my insurance carrier, I agree to make arrangements for prompt payment. If any over-payment occurs, the amount will be credited to the account. I also know that it is my right to request for any reimbursement that may be owed.

Recording

I understand that Clear Lakes Dental strictly prohibits any form of recording, including but not limited to, audio, video, and photographic recording, within the dental office. This includes recording of treatment procedures, consultations, and conversations between patients and staff. I acknowledge that the dental office takes patient privacy and confidentiality seriously and strives to provide a safe and secure environment for all patients and staff members.

COVID19 Risk Acknowledgement

I accept that there is an increased risk of contracting the COVID19 virus in the dental office or during dental treatment. I further confirm that I understand and accept the additional risk of contracting COVID19 from contact at this office. I also understand that I could contract the COVID19 virus outside this office and unrelated to my working here. I hereby release, covenant not to sue, discharge, and hold harmless the clinic, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the clinic, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after my dental appointment.

Tele Dentistry
I understand that I may be seen through teledentistry in the future, and I acknowledge that the recommended treatment has limitations. These limitations include the potential for incomplete diagnosis due to the lack of a clinical examination and possible technical issues like poor internet connections. Additionally, remote treatment options are limited, and teledentistry may not be suitable for emergencies; in such cases, I should contact emergency services or visit another dental clinic.

Enhanced Oral Cancer Screening

At Clear Lakes Dental, we provide enhanced oral cancer screening for your benefit. If the screening is not covered by your insurance, the cost will be waived and not billed to you