PERSON RESPONSIBLE FOR ACCOUNT (If patient is under 18 years old)

SECONDARY DENTAL INSURANCE INFORMATION

I acknowledge that I am aware of the Provider's Notice of Privacy Practices posted at the Family Dental Center.

 

The Notice of Privacy Practices describes how identifiable health information may be used and disclosed and states my rights with respect to my medical information.

 

I understand that The Family Dental Center has the right to revise these information practices and to amend the Notice of Privacy Practices. I understand that in the event that the Notice is revised, the revision will be posted at The Family Dental Center. Upon request, I may obtain a copy of the Privacy Practices Policy.

I hereby give permission for the release of any or all medical and dental information to the person(s) listed below:

(Information released obove will be reloted to today's appointment and all subsequent appointments at The Family Dental Center)

 

I understand this authorization will not expire and I may revoke or change this request for confidential communication at any time by contacting The Family Dental Center in writing.

FINANCIAL & CANCELLATION/FAILURE POLICIES

Financial Policy: Due to increasing changes with insurance benefits, and in an effort to maintain communication as our practice grows, we wish to inform you of our financial policy.

• Fees for service are due at the time of your visit.
• Please let the front staff know of any changes in your dental insurance.
• If you have dental insurance, your deductible and co-payment are due at the time of your visit. We will file your insurance claim for you.
• We accept cash, check, money order, VISA, MasterCard, and CareCredit.

Please note it is the responsibility of each patient to check with his/her insurance carrier for benefit coverage and to understand his/her dental insurance policy. If, for any reason, the estimated amount Is not paid by your insurance company, it becomes your obligation.

 

Cancellation/Failure Policy: The Family Dental Center values your time and will do our best to accommodate you and your family's work/home schedules. We use many different methods of appointment confirmation from postcards, phone calls, emails, and text messaging to remind you of your appointment(s) with us. If you cancel an appointment, we ask for a 48-hour notice. If you are unable to give us a two-day notice, we ask that you call as soon as possible to cancel/reschedule your appointment. Please note: we are unable to cancel or reschedule appointments via email or text. An answering machine is available to take your cancellation after hours.

 

Failure Policy: The Family Dental Center reserves the right to charge for any failed or missed appointments when patients do not show for their scheduled time and do not attempt to call our office to cancel or reschedule prior to set appointment. If multiple appointments are missed in a twelve-month period or a pattern of consistent rescheduling occurs, we may ask the patient to seek his/her dental care elsewhere.

 

I have read and understand the above policies. I agree to be responsible for the balance due on my account. I also understand The Family Dental Center reserves the right to charge for missed/failed appointments.

In order to serve you better during oral cancer screenings, please answer the following:

Women Only: 11-13

I certify that I have read and understand the above Information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.  

The Family Dental Center has my permission to use my child(ren's) photograph publicly to promote the office. I understand that the images may be used in print in office, or on The Family Dental Center website and social media accounts. I also understand that no compensation shall become payable to me by reason of such use.

The Family Dental Center has my permission to use my photograph publicly to promote the office.I understand that the images may be used in print in office, or on The Family Dental Center website and social media accounts. I also understand that no compensation shall become payable to me by reason of such use.