Welcome to our office! The following is an explanation of our policies regarding patient accounts, privacy practices, and consent for treatment. If you need any additional explanation, we will be happy to answer any questions.

GENERAL CONSENT

Thank you for choosing our office for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the benefits of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to offset the benefits of treatment, but should be considered when making treatment decisions.

Benefits of dental treatment can include: relief of pain, the ability to chew properly, and the confidence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually any dental procedure, including:

1. Drug or chemical reaction. Dental materials and medications may trigger allergic or sensitivity reaction.
2. Long-term numbness (paresthesia). Local anesthetic, or its administration, while almost always adequate to allow comfortable care, can result in transient, or in rare instances, permanent numbness.
3. Muscle or joint tenderness. Holding one’s mouth open can result in muscle or jaw joint tenderness, or in a predisposed patient, precipitate a TMJ disorder.
4. Sensitivity in teeth or gums, infection, or bleeding.
5. Swallowing or inhaling small objects.

While we follow procedural guidelines which most often lead to a clinical success, just like in any other pursuit in health care, not everything turns out the way it is planned. We will do our best to assure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you.

1. The patient is responsible for all fees for services rendered, regardless of the insurance company’s determination of the benefits payable. The patient is financially responsible for any and all fees for services rendered and not covered by your insurance carrier.
2. It is the patient’s responsibility to understand the limitations and maximum amounts f your insurance benefits. We cannot be responsible for tracking policy limitations of your policy.
3. You understand and agree that your dental insurance is a contract between yourself, your employer and the insurance carrier. Dr. Jones agrees to accept any benefits and process claims as a courtesy to you.
4. I authorize and direct insurance payments to Dr. David Jones. I authorize release of information pertaining to my dental treatment to my insurance carrier.
5. We reserve the right to charge patients who do not cancel their appointments within 24 hours.

Notice of Privacy Practices

Our Notice of Privacy Practices is displayed in our lobby on the wall to the right of the door. Please feel free to review these practices. If you would like a copy of our Privacy Practices, we will be happy to do so.

I have read and understood the financial policies and general consent of this office and have been made aware of the Notice of Privacy Practices.

 

_______________________________________ Patient’s Signature	__________ Date
_______________________________________ Parent’s Signature (If the patient is a minor)	__________ Date