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Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.
Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]
Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.
When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.
Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).
Insured Patients:
As a courtesy, we will process your insurance claims for you. Please understand the following:
All Patients:
Please be aware of the following:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Payment is due in full at the time of treatment unless prior arrangements have been approved.
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs fo dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time.
