MUST BE COMPLETED AND SUBMITTED PRIOR TO YOUR FIRST APPOINTMENT

Rose Dental is committed to providing quality oral health care services that are responsive to your needs and those of your family. Because you play an important role in your healthcare team, we encourage you to become familiar with your rights and responsibilities.

You have a right to receive quality oral health care services in a safe environment.
You have the right to obtain information on the types of oral health services we offer as well as the service limitations and costs of these services.
You have the right to be fully informed of your oral health condition, diagnosis, treatment options, and prognosis in a way that you can understand. This will allow you to give your informed consent.
You have the right to ask questions and seek clarification when information is unclear so that you understand the care, services or treatment available, and the risks and benefits of treatment. This includes understanding the consequences of treatment refusal.
You have the right to refuse any care, services or treatments suggested to you, except in certain very limited circumstances where an emergency may arise.

It is your responsibility to collaborate with the staff in the assessment and improvement of your oral health condition and to provide the relevant information about your values, needs, and beliefs.
It is your responsibility to provide correct and complete information about your health (including dental/medical history, illnesses, hospitalization, medications, etc) that may influence the care, services, and treatment you receive. You must also notify your dentist, specialist or oral health care team of any changes in your health condition.
It is your responsibility to follow the treatment plan as established and agreed to with your dentist, specialist or oral health care team. It is your responsibility to report if you do not understand the planned treatment or your part in the plan.
It is your responsibility to keep your appointments or to provide timely notice of cancellation (48 hours) if necessary.
It is your responsibility to pay your invoices as soon as possible.

By typing my name below, I acknowledge that I have fully read and understood my right and responsibilities as a patient of Dr. Aurora Moldovan at Rose Dental.