Patient Agreements

Patient Agreements

Our Mission

In our dental practice, we strive to serve the needs of you, our valued patients, to the best of our ability. We aim to provide the highest quality dental care in a relaxed and comfortable environment. We understand that you have a choice in dental care, and we thank you for choosing our office.​​​​​​​
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Name*

Confirmation

It is imperative that you confirm your scheduled appointment with our office at least 2 business days prior to your appointment. Your appointment time is reserved for you. We do not double book our providers. Confirming your appointment allows us to provide quality care and appointment times for all of our patients. You may reach us during office hours, leave a voice mail message after hours, or send an email to adh.office@adhaz.com. If we have not heard from you, we will make every effort to contact you at the numbers you have provided us. Unconfirmed appointments are subject to cancellation.
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Arrival

We understand that your time is limited and valuable. We will make every effort to see you at your appointed time. For this reason, we ask you to be ready for treatment at your appointed time. We understand that unforeseen circumstances can cause delays in your arrival. In order to provide you with the necessary time to complete your treatment, we may ask that you reschedule any appointment that we cannot complete during your scheduled time.
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Minors

Children under the age of 18 must be accompanied by a parent or legal guardian for the first dental visit in our office. Future dental treatment will not be performed without prior arrangements between our office and a consenting adult. If a minor child arrives unattended for dental treatment, the appointment will be rescheduled.
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Length of Appointment

In order to serve you with our undivided attention, we schedule your dental treatment as a block of time. This allows us to focus only on you and assures you that you will be finished with your dental appointment on time. For any appointment longer than 60 minutes, we ask for one-half of your payment when the appointment is made and the second half at your scheduled appointment
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Cancellations and Rescheduling​​​​​​​

We understand that it may become necessary to change an appointment. As a courtesy to our staff and to our other patients, we ask that you let us know immediately if you cannot keep your appointment. Appointments canceled or rescheduled fewer than 2 business days in advance may be assessed a $75.00 cancellation fee
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Dental Insurance​​​​​​​

As a professional courtesy, we will submit your dental insurance claims. While we will assist you in obtaining benefit information, we are not privileged with the detailed provisions of your particular plan. All estimates provided in our office are based on general benefit information. Questions regarding your specific dental benefits should be directed to your insurance company. You are ultimately responsible for all charges incurred in our office. You will receive a statement from our office for any unpaid balances.
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E-Signature

Date Signed