Patient Agreement Form
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1Patient Agreement Form
We know that as a patient, you have a large array of choices when it comes to picking the right dental
practice for you. We appreciate you choosing us as your dental care provider. As a patient, you should
expect nothing but the best from your dental office in terms of dental care, a welcoming and friendly
atmosphere, and a respectful dental team. We strive to create your ideal office and hope to foster a
relationship of mutual respect between patient and provider.
As a patient in our office, we will provide you with:
A patient comfort menu
•
A soothing atmosphere
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Billing insurance for you
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Financial arrangements
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Highest level in patient care
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State of the art technology
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Digital X‐rays (less radiation)
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A gentle and caring team
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Comfortable care for high fear patients
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General, cosmetic, preventative, implant, and Invisalign Dentistry
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Advanced laser treatment for gum and bone loss
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Teeth whitening procedures
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As a patient of our office we would appreciate the following:
Prompt payment for your treatment at time of service
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At least 48 business hour notification of appointment cancellation
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On time arrival for your appointments
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Informing us of changes to health, address, insurance, etc.
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Respect and courtesy to our staff and Doctor
•
Patient Name:__________________________________________
Patient Signature:_______________________________________
Date:__________________________________________________
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Parent category: Business