Patient Information (Page 3 of 4) in pdf

Consent for Services

(Please read this section carefully and initial next to each item.)

A) Financial Policy: I understand that, as a condition of my treatment by this office, financial arrangements must be made in

advance prior to treatment being performed. Any service performed without previous financial arrangements must be paid in full at

the time of service.

Initial: _____

B) Emergency Services: I understand that all emergency services, unless otherwise previously arranged, must be paid in full at

the time of service.

Initial: _____

C) Insurance: I understand that any insurance estimates given by this office are estimates only. This dental office cannot render

services based on the assumption that my charges will be paid by my insurance company. It is my responsibility to understand and

inform the dental office of my insurance benefits. I further understand that all dental services rendered on my behalf are ultimately

my full financial responsibility and/or the responsibility of my authorized guardian/guarantor. Should this office agree to accept

assignment of benefit from my insurance, any balance remaining after my insurance has been billed is my responsibility.

Initial: ____

D) Warranty: I understand that if, for any reason other than traumatic accident or patient non-compliance (See Section E for

reference), my restorations fail or break, they will be replaced by the dental office of McMillan Sedation Dentistry at no charge for

the first three years following the permanent delivery date. I understand that the warranty work must be performed by the office of

McMillan Sedation Dentistry in order to comply with the terms of my warranty. After the completion of the first full three years

following the initial treatment, I will be responsible for the current lab fee for the replacement of my restoration through years 4 and 5

after my delivery, and the total cost (100%) after 5 complete years.

Initial: _____

E) Patient Responsibility: I understand that in order to initiate my warranty, it is my responsibility to complete all recommended

restorative treatment and follow recommended maintenance schedules, including and not limited to hygiene appointments, post-

operative home care, post-op appointments, delivery of permanent restorations and prosthetics, and custom occlusal guard

protection and that this treatment must be performed at the dental office of McMillan Sedation Dentistry. If my treatment and

maintenance plans are not followed as recommended, and/or appointments are missed, adverse results could affect my dental

health and insurance coverage. If I do not proceed with my recommended treatment plan in a timely manner, I understand that I

could risk requiring further treatment for the involved teeth, supportive tissues, adjacent and opposing teeth, and/or muscles or

joints; and upon such circumstance, any warranty may be revoked at the doctor’s sole discretion.

Initial: _____

F) Cancellation Policy: I understand that this office reserves the right to charge a cancellation fee of $75 per hour in the event that

I fail to appear and/or give 2 full business days notice to reschedule or cancel any hygiene appointment. I understand that this

office reserves the right to charge a cancellation fee of $150 per hour in the event that I fail to appear and/or give 2 full business

days notice to reschedule or cancel any appointment with Dr. McMillan. Exceptions will be made at the doctor’s sole discretion for

circumstances related to or involving true medical emergency or death in the family. I further understand that my cancellation fee

must be paid prior to scheduling any additional or future appointments on my or my family’s behalf. This office will make every

reasonable effort to remind me of my scheduled appointments; however I agree and understand that it is my responsibility to

remember and attend my appointments.

Initial: _____

G) Treatment Fees: I understand that fee estimates can only be extended for a period of 30 days from the date of the patient

examination.

Initial: _____

H) Patient Contact Information: I grant my permission to you or your assignee, to telephone, mail, or e-mail me at any/all of the

contact information listed above to discuss matters related to this form and or my patient care. Initial: _____

I) HIPPA: I understand that this office complies with the Healthcare Information Privacy Practices Act (HIPPA). A full explanation is

available for me at the front desk should I require more information.

Initial: _____

By signing this document, I agree to accept the terms as listed above. I understand that it is my responsibility to read and comply

with all terms, policies, and stipulations listed in this document. In the event that I need further clarification concerning the items set

forth on this form, I have the right and responsibility to inform the office of McMillan Sedation Dentistry prior to signing. My

signature on this document will serve as verification that I understand all terms, policies and stipulations as put forth in this

document and I am in agreement with them. I further understand that I am responsible for the entire balance of my dental

treatment rendered on my behalf. I understand that in the event that my balance with this office becomes delinquent, this office will

forward my account information to a collection agency and/or collection attorney. I further agree that I am liable to pay all costs and

reasonable attorney fees if suit be instituted or further action is required to collect my delinquent balance.

I have read the above conditions of treatment and payment and agree to their content.

____________________________________ Date: _____________ Relationship to Patient:

Signature of patient, parent or guardian

____________________________________ Date: _____________

Print Name of patient, parent or guardian

____________________________________ Date: _____________ Relationship to Patient:

Signature of

guarantor of payment/responsible party

Patient Information Page 3

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