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Appointments and Costs
As a courtesy, we attempt to confirm most appointments 48 hours in advance. However, if we are unable to reach you, keeping your appointment is your responsibility.
We require an advanced 24 hour notice of cancellation or request to reschedule an appointment.
Failure to reschedule or cancel your appointment in this time frame will result in a charge of $50 per 1/2 hour appointment(s) for general and $100 per 1/2 hour appointment(s) with specialists. Please note that all Monday appointments shall be canceled by 5 P.M. Friday or a broken appointment charge will be applied.
As a condition of treatment by this office, financial arrangements must be made in advance. We depend upon timely reimbursement for the costs incurred in rendering care. Financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.
Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any insurance payment 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.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements are satisfied.
I understand that any fee estimate for dental care can only be extended for period of six months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of time or condition hereunder shall not constitute a waiver of any other
term or condition and I further agree as the responsible party to pay all costs including but not limited to outside collection fees, bank fee, penalties and reasonable attorney fees.
I grant permission to you or your assignee, to telephone me to discuss this statement or my treatment.
With miracles of modern dentistry, we can restore function, aesthetics and comfort to the oral structures, by providing state of the art dental treatment to our patients. Dental treatments are usually successful with excellent outcomes. However, since dentistry is not an exact science, and there are variations in patients' physiological response to dental treatments, in remote occasions complications may occur.
We are trained and equipped to handle most complications. In case of problems with dental restorations, they will be repaired or replaced for a period of one year without charge to the patient. It is our moral and legal duty to inform our patients of the possibility of complications however unusual and remote they may be.
Dental Material Fact Sheet
I have received a copy of the Dental Material Fact Sheet
, Prepared by the California Dental Board and provided to me by
In reading and signing this form, it is understood that ENGLISH is the language that I understand and use to communicate. Otherwise, this document has been translated to me and I fully understand its content.
Change in Treatment Plan
I understand that due to changing conditions, it may be necessary to change or add procedures, due to new findings not present during the initial examination and treatment planning or changes in the priorities of the treatment sequences. I understand that I will be informed of these changes before the initiation of the clinical procedures.
I have been advised, and consent to the following:
- I am to receive a full mouth series of X-RAYS every five years or when in the judgment of the doctor, it is necessary. This series of radiographs will provide diagnostic information and documentation for my teeth and surrounding oral tissues.
- I will receive periodic examination and X-rays for the correct and accurate diagnosis of my oral condition.
- I will consent to diagnostic X-rays at a frequency as assessed by the doctor.
- I understand that all reasonable precautions will be taken to minimize my exposure to unnecessary radiation.
I have read the above statements and have received a copy of them if requested, and recognize their importance in helping me
make decisions. My initials indicate that I have read and understand this consent document. recognize that failures can occur for all kinds of reasons and that complications can occur in any procedure. I also understand that, where decay has occurred, or tooth has fractured or abscessed, that these same forces are still working on the tooth even after it has been restored: therefore, decay or fracture can still occur as the restored tooth is no better than what nature has given in the first place. If for any reason a conflict or disagreement should arise will first present such conflict or disagreement to my attending dentist in order to resolve the problem. If we are unable to agree on a solution, then agree to take the problem to a reconciliation / mediation board such as the dental society and agree to accept their resolution in lieu of pursuing remedies by way of litigation. Also understand that this agreement is binding on my heirs and all other family members. Now give my consent to the attending dentist to render to me the dental treatment that we have agreed is necessary I also agree to reimburse the attending dentist for all services rendered
to me and I am aware that the payment for these services is due at the time they are rendered.