I authorize the specialist to conduct a dental examination and perform treatment as deemed necessary for proper dental care
I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.
I understand that I am responsible for payments in full for all professional services at the time each service is performed. I understand that an estimate of treatment costs will be given to all new and recall patients and that actual cost for services may be higher or lower. By signing this form, I revoke all previous agreements to the contrary and agree to be responsible for payment of service not paid in whole or in part by my dental care provider.
I authorize the communication and release of information concerning my (my child’s) related treatment to other dentists or specialists.
I authorize the communication and release of information contained in my claim forms to my insurance provider/plan administrator.
I understand that prior to any scheduled surgical procedure, the office may contact me in advance to review and update my medical history, confirm my pharmacy information, and review or obtain necessary consent forms. I acknowledge that accurate and current medical and pharmacy information is required to ensure safe treatment. I further understand that prescriptions related to my procedure may be prepared and forwarded to my pharmacy prior to the date of surgery when clinically appropriate.
APPOINTMENT POLICY: Our policy requires that if you wish to cancel an appointment, you must provide our office with 2 business days’ notice. Please note that we are unable to accept cancellations via email or after hours. Appointment cancellations with less than 2 business days’ notice may incur a $50 fee.
SURGICAL APPOINTMENT DEPOSIT POLICY: Surgical procedures require advance preparation and dedicated clinical time. A non-refundable deposit of $300 is required two (2) weeks prior to the scheduled surgery date in order to secure the appointment. This deposit will be applied toward the total cost of the procedure. If a surgical appointment is cancelled or rescheduled with less than two (2) weeks’ notice, the $300 deposit will be forfeited. Failure to provide the required deposit by the specified deadline may result in cancellation of the surgical appointment.
I have read the above conditions and agree with their content.