Patient Information Form

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

METHOD OF PAYMENT: As always, if you have insurance, we are happy to process all the paperwork at no charge to you. HOWEVER, WE DO ASK THAT YOU PAY YOUR ESTIMATED PORTION AT THE TIME OF THE APPOINTMENT unless prior arrangements have been made.

• Provide and coordinate my treatment among a number of health care providers involved in that treatment directly and indirectly
• Obtain payment from third-party payers for my health care services
• Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

A No Show fee will be charged to your account if:

• You do not show up for you scheduled appointment or
• You do not cancel your scheduled appointment at least 24 hours prior to your scheduled appointment time.

This includes all established appointments, dental procedures, dental cleanings and cosmetic appointments. The fees are as follows:

• 1st missed appointment: If an appointment is missed or canceled within the 24-hour window, a letter will be sent to your home reminding you of our policy. We reserve the right to charge you $50 for each hour appointment time scheduled.
• 2nd missed appointment: After your second missed appointment, another letter will be sent to your home notifying you, of a $50 charge to your account. In order for you to make another appointment this charge must be paid.
• 3rd missed appointment: Will be charged the full appointment fee and or dismissal from our practice.

Our office understands that true emergencies do happen. If this is the case, please provide us with adequate reasons or proof and the missed appointment will be removed from your accounts record.

LATE ARRIVAL: When we reserve time for you, we require all of the scheduled time to provide you with the best quality work possible. When you are late it decreases our ability to accomplish this. Please try to arrive on time so that we are not late for our remaining appointments of the day.

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient’s account and that he or she is personally responsible for payment of all dental services not covered by the insurance company. This office will help prepare the patient's insurance form or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. Patients are required to pay their estimated portion of the services rendered at the time of service.

A service charge of 1 ½ per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of three months from the date of the patient’s examination and is subject to insurance benefits.

In consideration for the professional services rendered to me, or at my request, by the doctor, I agree to pay therefore the reasonable value of said doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of anytime or condition hereunder shall not constitute a waiver of any further term of condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I understand that I will be charged a $50.00 “Broken Appointment Fee” if I fail to keep an appointment or if I do not give at least 24 hours notice when canceling an appointment except in the case of an emergency.

I grant my permission to you or your assignee, to telephone me at home, at my work, or my cell phone to discuss matters related to this form.

AUTHORIZATION: I hereby authorize payment directly to the Dental Office. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and medical history are correct to the best of my knowledge.

I have read the above conditions of treatment and payment and agree to their consent.