Updated Policies

Patient Name *
Patient Name
Please Read Before Signing
1. Please bring your Insurance card with you at each visit. 2. We will attempt to verify your insurance at each visit. If coverage can not be confirmed you will be expected to pay the cost of treatment the day of service. We make every effort to be respectful of our patient’s time and schedules and ask that you do the same. Please review our following policy: 1. We require 24 hours notice to reschedule all appointments with the exception of sedation or anesthesia appointments which require 48 hours to reschedule. 2. For your convenience we have a 24 hour voicemail should you need to call after normal business hours. You may leave a message notifying us of your change. 3. As a courtesy to all of our patients we use an automated phone messaging system that calls two days prior to your child/children’s dental appointment. 4. In the event we are not able to reach you, you are still responsible for keeping your appointment. 5. NOT SHOWING FOR A SCHEDULED APPOINTMENT CAN RESULT IN DISMISSAL FROM THE PRACTICE.
Typing your full name here constitutes your legal signature.
Date
Date