Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESCANCELLATION POLICY
If you cannot keep an appointment, please notify us as soon as possible.At the first failed appointment, since unforeseen events do happen, there will be no penalty.
At a second failed appointment, within a one-year period, a fee will be added to your account.
At a third failed appointment, within a one-year period, your ability to receive dental care at this office will be terminated.
A failed appointment is any appointment for which we fail to receive at least 24-hour business hours advance notice of your inability to attend. "Business hours advance notice" is defined as any business day during regular business hours. For example, to cancel a Monday 10:00 a.m. appointment, this office would need to be notified before 10:00 a.m. the previous Wednesday. This does not include holidays, seasonal closures, vacations, weekends, or after hours. You are welcome to leave a recorded message; however, you are responsible for confirming during regular business hours that the message was received.
The worth of the "reason" for the failed appointment will not be considered.
The above policy may be waived during severe weather conditions. If you are unable/unwilling to attend a scheduled appointment due to severe weather conditions, and are unable to provide us with 24 business hour advance notice, please call as soon as possible. If we do not receive at least one (1) hour notice prior to the scheduled appointment, the above policy will be exercised.
