Welcome to our office. We appreciate the confidence you place with us to provide dental services.To assist us in serving you, please complete the following forms. The information provided onall forms are important to your dental health.
We currently only take Cash, Check, VISA, MC, AMX, & CareCredit for payment.
I hereby authorize payment directly to Dr. Brandon Atkinson, from my group insurance benefits. Iunderstand that I am responsible for all costs of dental treatment and/or insurance co-pays.
Appointment Policy: We ask that you provide us with at least 48 hours notice if you need to cancel yourappointment. We recognize that there are times when urgent situations require last minute appointmentcancellations. We reserve time especially for you and with sufficient notice, we can fill that time. We strive toprovide you the best dental care possible and appreciate your efforts in giving your dental appointments thepriority they need. A $75 fee will be assessed for any cancelled appointments with less than 24 hour notice.
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
I have been informed of my healthcare provider’s Notice of Privacy Practices ( located behind paperwork on clipboard) which contains a complete a more complete description and disclosures of my PHI – Protected Health Information. I have been given the right to review and receive a copy if I chose.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.