Our dental team at Danville Pediatric Dentistry is committed to providing your child with excellent dental care. In return we expect you to attend every scheduled appointment on time.
- When you miss an appointment it may not cost you anything but there are costs to others.
- Make sure you keep every appointment. This appointment is for you.
- If you are not going to keep your dental appointment notify the office at least 24 hours ahead of time.
- If you do not notify the office 24 hours prior to the appointment and miss your appointment 2 times, you will no longer be able to come to this office for your dental care.
You and your child have the right to:
- Be treated with respect.
- Receive needed dental services.
- Privacy and confidentiality.
- Receive information about your oral health care and treatment options.
- Help make choices about your dental care.
You and your child have the responsibility to:
- Bring your current Medicaid or insurance card each time you come to an appointment.
- Tell your dentist when you have concerns about your oral health.
- Follow the advice and treatment plan of your dentist.
- Tell your dentist when the treatment plan is against your wishes.
- Keep all dental appointments.
- Show up on time for all dental appointments.
The dentist and dental team have the right to:
- Be treated with respect.
- Enforce all stated office policies regarding failed appointments, payment requirements, and acceptable behavior in the office.
The dentist and dental team have the responsibility to:
- Inform you of all needed treatment and tell you what could happen to your oral health if you do not have the treatment.
- Keep all appointments scheduled with you.
- Be on time for appointments scheduled with you, or tell you when they cannot be on time.
I have read and understand the information given to me in this agreement. I have had the chance to ask the dentist and dental team questions about the information.
I agree to show up for appointments that I schedule with Danville Pediatric Dentistry and to come to appointments on time.