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Office Policy Form


We want to involve you in all decisions concerning procedures you may need. We take informed consent very seriously in our office. Dental treatment and procedures are not to be taken for granted as being routine or without risk of complications. As with any medical treatment, including dental treatment, there are no guarantees that the results will be as planned and to each individual's satisfaction. When dealing with the human body there are many variables, some are predictable and others are not. Complication rates in dentistry are very low but do exist. Whenever drilling is involved, even a simple cavity can lead to pulpal (nerve) problems, abscesses, fractured tooth, and/or post treatment pain to biting and temperature extremes (hot and cold). These kinds of complaints can be transient or may persist requiring further treatments. The above examples are some samples of possible complications with dental treatment but complications are not limited to these. In general, complications include but are not limited to pain, swelling, bleeding, infection, and nerve problems.


Our practice is dedicated to providing quality, comprehensive dental care for your entire family. We emphasize education and prevention as they are the key to optimal dental health. We value our patients' time and strive to make their concerns our priority. Missed appointments and failure to comply with recommended treatment schedules or procedures prevents us from achieving our goal of optimum health for you. If you miss an appointment we ask that you call to reschedule. It is critical to maintain consistent care in order to avoid setbacks in your oral health. It is our goal to eliminate the potential for dental emergencies by providing exceptional care for you before any problems arise. In the rare instance that you do have an emergency we will provide you with the next available emergency appointment. Treatment recommendations are based on your health and not on your insurance or lack thereof. If you have insurance it is your responsibility to be aware of your benefits. Remember that insurance companies are not concerned about your health, nor do they make decisions with your best interest in mind - we do. As a courtesy we will provide you with an estimate of benefits and payment. However, your benefits are a contract between you and your insurance company and you are fully responsible for any treatment performed. We cannot be responsible for what your insurance will or will not cover.

Cancellations and Broken Appointments: We feel that our patient's time is valuable. When your appointment is made, a reserved, your records are prepared, and special instruments are readied for your visit. We request that you be on time for your visits. If you are more than 10 minutes late, you may have to reschedule your appointment. In return, we will do our best to start your appointment on time. Except for emergency treatment for another patient, you can expect us to be prompt. We reserve the right to charge for any appointment(s) broken without 48 hours notice. The charge will be $75.00 and this fee is not covered by insurance. We understand that extreme or unavoidable emergencies or ciō€€¨cumstances do arise which may require you to change your appointment and this will be taken into consideration. Financial Policy: Your payment is due at time of service. Checks returned from the bank are subject to a $35 service fee. If your account is sent to our collection agency you will be responsible for collection and court costs along with attorney's fees.

Thank you for choosing our office. We want to provide you with the best dental care possible. If you have any questions regarding our policies and your treatment, please do not hesitate to ask.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.