General consent form and office financial policy

I, ______, consent to be a patient at the above named office and agree to a clinical examination and radiographs if needed. I also understand and consent to the following:

  1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.
  1. I will do my best to provide a thorough and complete medical history, supply a full list of my medications with dosages, and allow my dentist to communicate with my other medical practitioners to inquire about my health history.
  1. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about. I am ultimately responsible for making all the decisions about my oral health. My dentist and my dental team will do their best to help me make the best informed decision. If I choose to do so, I can deny any treatment recommended.
  1. I understand that any branch of medicine, including dentistry, can involve unanticipated results.Because of that, the treatment outcomes, restoration longevity, or prognoses cannot be guaranteed. My treatment plan may change or evolve at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.
  1. If, I need to change myscheduled appointment, I amasked to give 24hr notice or one full business day. Failure to do sowill lead to a chargeof $60.00 per hour ($60.00 minimum). Amessage on the answering machine afterhours for the next business day cancelation is considered a late cancellation. If, I arrive late to my appointment the staff will do everything they can to accommodate me. However, the procedure cannot be completed same day because of my late arrival and the appointment need to be rescheduled, I will be charged a late fee. The fee amount can be changed without an advance notice. Repeated missed or cancelled appointments can lead to loss of patient privileges.
  2. Thecosts of my treatment or insurance copayments are due at the time of service.Cash, checks or credit cards are accepted. A deposit of at least half of my dues will be collected before the start any treatment that involves a laboratory. The remaining balance will be due at the time of delivery of the appliance. If my account is not paid in full,I will receive a statement with a specific due date. Any remaining balance on my account after that due date will incur an interest of 15% APR. Bellevue Harmony Dental reserves the right to transfer certain outstanding accounts to a collection agency.
  1. If Ineed a financial arrangement, I willarrange that before my treatment is initiated.I will have to sign a contract for the specific treatment with agreed upon total number of payments, due dates and potential penalties. Offering a financial option is a courtesy and may not be offered to all patients.
  1. I understand that Bellevue Harmony Dental cannot guarantee an insurance payment. If insurance pre-estimate is given or a procedure has been preapproved, it is still not a guarantee for payment. Ultimately I am responsible for knowing my insurance plan and limitations. If I am unsure, it is my responsibility to communicate with my insurance. I understand that I am responsible for anycosts associated with my treatment including any procedures that my insurance may not cover.

Additional disclosure authority:

I addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby authorize disclosure of my personal protected information as well as payment and operations information to:

Any member of my immediate family ______Yes□ ______No□

Spouse only______Yes□ ______No□

Other (specify) ______Yes□______No□

Can we leave a message with information pertaining your treatment or payment on:

A voice mail? Yes □______No□______

Email? Yes□______No□______

______

Patient or Guardian NameDate