PERSONAL EVALUATION
APPOINTMENT CANCELLATIONS
As a courtesy, we make every effort to confirm your appointment one day in advance. However, it should be noted it is your responsibility to keep all appointments. We request a MINIMUM OF 24 HOURS to change or cancel an appointment. A fee may be incurred for all failed or late cancellations. For more than two failed or cancelled appointments you may be placed on same day only appointment basis.
DENTAL INSURANCE
If you have insurance coverage, our staff does their best to determine a proper ESTIMATE for you as a courtesy. Due to the many insurance companies and plans we cannot always predict the actual payments your insurance carrier will make. You are required to make payment of your full estimated responsibility upon services rendered. After payments are received from your insurance carrier, you may be required to make additional payments, have a credit issued to your account for future services or may be eligible for a refund. By signing this form, I hereby authorize and direct payment of dental benefits from my insurance company to New England Smile Orthdontics.
AUTHORIZATION AND RELEASE
I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child during the period of such dental care to third party payers and/or health practitioners.
OFFICE SAFETY AND SECURITY
Please be aware that our office has on site security video and audio recordings to protect patients and staff from unforeseen events. By entering our premises you consent to video and audio recordings. If you do not consent to video and audio recordings from our security cameras, then you are welcome to contact us via phone instead. However, security cameras will not be turned off for any individual basis for the safety of our patients and staff.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have read/received a copy of this office’s Notice of Privacy Practices.
You can find this office’s Notice of Privacy Practices within the HIPAA Privacy Statement located at the bottom of our main web page.