• Dental Hygiene

  • 1. Date of last dental cleaning?
     - -
  • 3. What do you use to clean your teeth/gums?
  • 4. Have you ever been told that you have periodontal disease?
  • 5. Have you ever head a deep cleaning?
  • 6. Do your gums bleed when brushing/flossing?
  • 7. Are you currently using any prescription toothpaste or mouthwash?

  • Smile Solutions DMD Appointment Cancellation Policy Form

  • Practice Name: Smile Solutions DMD
    Address: 2221 Transcontinental Dr. Suite G, Metairie, LA 70001 Phone: (504)-613-5100
    Email: Smitesolutionsdmd@gmail.com

    Patient Information

  • Date of birth
     - -
  • Format: (000) 000-0000.

  • Cancellation Policy

    We understand that sometimes schedule adjustments are necessary. However, we require at least 24 hours notice for appointment cancellations or rescheduling.

    • Appointments canceled with less than 24 hours may incur a cancellation fee of $75.00.
    • Missed (no-show) appointments without any notice will also be subject to a fee.
    • Repeated cancellations or no-shows may result in limitations on future bookings.

     

    Acknowledgment and Signature
    I understand and agree to the terms of the cancellation policy stated above. I acknowledge that failure to provide sufficient notice or missing appointments may result in fees or scheduling restrictions.

  • Date
     - -
  • Should be Empty: