Office Policy
Cancellation Policy
48 Hour Notice of Cancellation
I agree to give 24 hour notice for cancellations or I will be liable pay the broken appointment fee. I understand that leaving a message after the office is closed the day (or weekend) before is not sufficient notice.
Health Information
I agree to disclose all previous illnesses and medical history. Undisclosed medical information and current medication, allergies or illness are risk factors.
Drugs, Latex and Medication
I understand that antibiotic and other medicines can cause allergic reactions and even life-threatening anaphylaxis. Also, some antibiotics interfere with birth-control pills. Latex allergy can cause rashes and itching. Epinephrine increases heart beat and depending on my health may be dangerous for me.
Needle Stick
If someone is inadvertently stuck with a needle used on me, I consent to have blood drawn for analysis.
Fillings, Crowns and un-anticipated Root Canal
Some teeth may need a root canal even after a simple filling. Fillings and crowns do take away tooth structure and a percentage of these teeth end up needing a root canal after the filling or crown is done.
Root Canals can fail
Root Canals can fail and may require additional treatment or I may end up having the tooth extracted.
Porcelain Crowns, Veneers, Bonding and Cosmetic Fillings
Porcelain Crowns, Veneers, cosmetic bonding and Cosmetic fillings are esthetically pleasing. However, I understand that if they chip or break after in use successfully, I am responsible for repairs or remakes. Once a crown, veneer, bonding or filling is placed, I understand the color cannot be changed.
Gum treatment and Requesting “Just a Cleaning”
If I don’t floss or if I smoke, I can expect to have deteriorating gum condition. I agree that if I need gum treatment I will not insist that I simply just need to get a cleaning.
Extractions and Surgery
I understand that all dental extractions or surgeries carry risks. Some are minor like a dry socket following an extraction. Some are life threatening such as post surgical infection or anaphylaxis.
Fee for Additional or Specialty Care
I understand that I may need treatment beyond what was originally planned (a crowned tooth becomes painful and needs a root canal), or I may be referred to a specialist for additional care (root canal was not successful) I agree to be financially responsible for the additional specialty care.
Limitations of Insurance Coverage
There are charges beyond what insurance will pay, for example Nitrous oxide, temporary dentures, tapping off crowns or bridges, whitening or cosmetic work. As a service to patients, this office will file insurance claims on their behalf. I understand that what may be quoted as my portion (co-payment) is only an estimate. I agree to be financially responsible for what insurance does not cover.
I do not expect guarantees in dental care. I have read the above and consent to agreement.