Dental Registration And History Form (Page 3 of 7) in pdf

Dental Registration And History Form Page 3

Acknowledgement

NOTICE OF PRIVACY PRACTICES

Atwood Family Dental hereby makes it known that all patient

information will remain private, unless it is required or requested to

share such information with another attending dentist, doctor, or the

patient's insurance company. This is done in compliance with HIPPA

Privacy Practices, and my signature below attests that I have been

informed of the Privacy Practices stated in this paragraph.

__________________________________________

(Signature of Patient, Parent, or Guardian)

Appointment Scheduling Policy

We understand that unplanned issues can come up and you may need to

reschedule an appointment. If that happens, we respectfully ask for

scheduled appointments to be rescheduled at least 24 hours in advance.

Our doctors & hygienists want to be available for your needs and the

needs of all our patients. When a patient does not show up for a

scheduled appointment, another patient loses an opportunity to be seen.

Although we have always had a policy, circumstances have caused us to

enforce a policy of charging for no-show appointments, and those

appointments not cancelled with at least 24 hour notice. As of December

2, 2013 there will be a fee of $50.00 per appointment hour assessed if

we do not receive a call 24 hours in advance to cancel or reschedule an

appointment.

Thank you for being a valued patient and for your understanding and

cooperation as we institute this policy. This policy will enable us to open

otherwise unused appointments to better serve the needs of all patients.

The Staff of Atwood Family Dental

Name:

Date:

Dental Registration And History Form Page 3