Policies for South Boston Dental Assoc.
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- Lily Andrews
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2 Policies for South Boston Dental Assoc. In an effort to avoid any misunderstanding, we would like to review our financial and office policies before you begin treatment in our office. Standard of care in this practice requires full mouth x-rays every 5 years, bitewings and exam every year. We will not treat patients without updated x-rays. Payment is expected at the time services are performed. We accept MasterCard. and Visa. For extensive services we offer low and no interest payment plans through Care Credit. For our patients with dental insurance our policy is as follows: You will need to supply us with the subscriber's information (name, date of birth. social security number, employer and ID#) as well as the name and address of the insurance company. We will do our best to answer any questions you may have about your insurance coverage but we always suggesthat you call or visit your insurance company's web site. As a courtesy to our patients, we will gladly submit the insurance claim to your insurance company. We will collect your estimated co payment and deductible at each visit. We make every effort to determine your insurance benefits when you receive treatment but consider your co payment an estimate until we receive payment from your insurance company. Please remember that any information we provide relative to your insurance coverage is our best estimate and NOT a guarantee of the paymenthat will be received. Appointment policy We reserve appointmentimes specifically for each patient so that we may provide the ultimate service. Please schedule your appointment carefully as there will be a charge to your account for any appointment cancelled without a24hour notice. Similarly, late arrivals can create scheduling problems with other patients. Please notify us if you are going to be late. If you have any questions about any of our policies, please feel free to ask any member of our staff. Signature Date
3 Informed Consent for General Dental procedures You, the patient, have the right to accept or reject dental treatment recommended by your dentist or hygienist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure. alternative treatments, or the option of no treatment. Do not consento treatment unless and until you discuss potentiat benefits, risks, and complications with your dentist and allof your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known riiks and complications, not matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist's advice and recomtnendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow tlte advice of your dentist, you may increase the chances of a poor outcome. Please read and initial the items below and sign at the bottom of the form. l. Treatment to be Provided I understand that during my course of treatment that the following care may be provided: Examinations PreventativeSeruices Restorations Crowns Bridges Other I'atients Initials 2. Drugs and Medications I utrderstand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or arraphylactic shock (severe allergic reaction). I understand thal delivery of local anesthesia may result in (but not limited to) cardiovascular response; anaphytactic reaction, or parasthesia. Patients' initials 3. Changes in Treatment plan I uttderstand that during treatment it may be necessary to change or add procedures because of conditions found while *orking on the teeth that rvere not discovereduring examination, the most common being root canal therapy following routine restorative. If this occurs we will inform you of the change before treatment is completed. patients Initials 4' I give. my permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable. patient Initials Patient Signature Date
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First Middle Initial Last. SSN: Date of Birth . Address: City: State: Zip: Home Phone: Cell Phone: Sex: M F
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