New Patient Onboarding

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

*Condition may require pre-medication prior to your visit to our office

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. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Payment is required at the time of service unless prior arrangements have been made. You, as a patient, are responsible for the full fee of your dental treatments. We will bill your insurance as a courtesy to you. All unpaid balances over 60 days are subject to a monthly interest charge.

I also authorize to have photographs of my face, jaws and teeth taken. I understand that these items will be used as a record of my care, and may be used for educational purposes. I further understand that if these items are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

We realize that emergencies and scheduling conflicts arise that are sometimes unavoidable. However, advance notice allows us to fulfill scheduling needs and keeps our office operating at its most efficient level. Due to reserving time and space for patient appointments, missed appointments are a significant inconvenience to your dentist, the office, and other patients. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot.

Patients are asked to arrive at their appointments before their scheduled time. A grace period of 10 minutes is permitted for unforeseen delays a patient may encounter.

A “no show” is a patient who fails to appear for a scheduled appointment without providing 48-hour notice. A rescheduled appointment that is less than the 48-hour cancellation notice is considered a cancellation and treated as such. There is a $50 charge per hour of scheduled treatment cancelled. This charge must be paid on or before the next scheduled appointment.

Should a patient continue to break appointments, we reserve the right to dismiss that patient from the practice.

Please sign below to confirm you have read the HIPAA Notice of Privacy Practices