Medical Conditions

Which of the following applies to you?

Office Policies

Although many dental offices are non-assignment, our office will accept direct billing of benefits from your insurance company as part of our client services. It is important for you to understand that there may be differences between our fees and what your insurance company will pay for treatment. You are responsible for any difference in fees. In order to provide direct billing to our patients, we will require our patients to provide us with a credit card on file. If we cannot calculate your balance at your dental visit with certainty, you will be required to pay 30%. This may result in a small balance or credit on your account. If a balance still remains upon receiving payment we will charge the remaining balance to the credit card.

Patient’s medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. By completing this form you are consenting to the collection, use, and disclosure of your personal information when permitted or required by law.

In order to facilitate direct billing, you agree to your clinical records, images, and/or x-rays to be released to your insurance provider(s) should they request it, or to support pre-authorizations, or billings. You also agree to our office sending pre-authorizations, or communicating with your insurance company to request coverage details of your insurance plan in order to determine your level of coverage and your co-pay.

Treatment and Maintenance Program

The #1 cause of tooth loss in adults is periodontal disease, which is linked to cardiovascular disease and other serious systemic diseases. Smiles Dental Group is committed to helping you manage and treat gingivitis and periodontal concerns. However, we require a commitment from you in order to achieve overall oral health.

In addition to proper and consistent care, you will be expected to maintain your regular scheduled periodontal therapy/ re-care appointments as recommended by your dental hygienist. If you need to change this or any dental appointment our office requires two business days’ notice in order to do so. Failure to provide adequate notice may result in a charge of $100.00 ($250.00 for surgical procedures or appointments exceeding 1.5 hours).

Please acknowledge that this is a general dental practice, not a specialist practice; however we do offer certain services such as dental implants, bone grafts, IV sedation, TMJ treatment, sleep apnea, orthodontics, wisdom teeth etc.

Please note that our standard dental cleaning appointments are scheduled for 1 hour. However, depending on your individual oral health needs: Including the presence of excessive buildup, periodontal disease, or other clinical factors; your cleaning may require more than one visit to complete thoroughly and safely. At the beginning of your visit, your dental provider will assess your condition and inform you if additional time or appointments are needed, as well as the expected chair time if it exceeds the standard 1 hour. Please also note that hygiene visits are billed based on units of time.

We require your signature below to indicate your consent to perform the dental and oral procedures necessary for treatment, including the use of local anesthetic and/or relative analgesia as indicated, and that you assume responsibility for the fees associated with those procedures and finance charges if you fail to do so within adequate time