GENERAL CONSENT
I consent to be a patient at this office and agree to a radiographic and clinical examination. I also understand and consent to the following:
GENERAL CARE
During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.
MEDICAL HISTORY
I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.
QUESTIONS
I am welcome to ask questions about any aspect of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
RISKS
I understand that there are certain inherent risks and consequences that may be associated with any surgical, dental, or anesthetic/sedative procedure(s). I understand that not every conceivable hazard can be listed. I realize the following possibilities exist, however infrequent or rare: allergic reactions to medications, anesthetics, materials, etc.; drug interactions and side effects; excessive bleeding (during the procedure and/or after the procedure); postoperative bruising and discomfort; blood clots anywhere in the body; postoperative infection or bone inflammation; bruising and/or vein inflammation at the site of injections; damage to adjacent teeth, restorations, and/or gum tissue. These are not probable results, they are statistical possibilities.
RESULTS
No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.
TREATMENT CHANGES
My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.
Financial Policy
To provide the highest level of care and service, payment is due at the time services are rendered unless prior financial arrangements have been made.
Patients with dental insurance understand that insurance coverage is a contract between the patient and their insurance provider. As a courtesy, we will assist in submitting claims and processing benefits; however, all charges remain the patient’s responsibility regardless of insurance reimbursement.
Balances outstanding beyond sixty (60) days may be subject to a finance charge of 1.5% per month (18% annually), unless alternative written arrangements have been established and honored.
Treatment estimates are valid for six (6) months from the date of examination and may be subject to change thereafter.
By receiving treatment from this practice, I agree to pay all fees for services rendered either at the time of treatment. If payment is not received within 30 days, or if I designate prior, my credit card on file may be charged for any outstanding balances due.
Cancellation Policy
We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be rescheduled at least 48 hours in advance.
Cancellations made with less than 48 hours notice will incur a $75 fee if the appointment was scheduled with a hygienist, and a $500 fee if the appointment was scheduled with a dentist.
Thank you for being a valued patient and for your understanding and cooperation. The policy will enable us to open otherwise unused appointments to better serve the needs of all patients.
Audio, Video, and Photography Policy
I understand that, as part of my dental care and treatment, The Practice Beverly Hills Boutique Dental may create audio recordings, video recordings, photographs, digital images, radiographs, intraoral scans, and other visual or audio documentation of me, my face, mouth, teeth, gums, and dental treatment (“Recordings”).
I acknowledge and understand that these Recordings may be medically necessary and beneficial for purposes including, but not limited to:
- Diagnosis and treatment planning
- Documentation of dental conditions and procedures
- Communication among healthcare providers and specialists
- Maintenance of accurate dental and legal records
- Quality assurance and case review
- Dental research, education, and professional training
- Practice marketing, advertising, website content, social media, publications, presentations, and other promotional materials
I understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential.
I do not expect compensation, financial or otherwise, for the use of these photographs.
GENERAL CONSENT
I consent to be a patient at this office and agree to a radiographic and clinical examination. I also understand and consent to the following:
GENERAL CARE
During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.
MEDICAL HISTORY
I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.
QUESTIONS
I am welcome to ask questions about any aspect of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
RISKS
I understand that there are certain inherent risks and consequences that may be associated with any surgical, dental, or anesthetic/sedative procedure(s). I understand that not every conceivable hazard can be listed. I realize the following possibilities exist, however infrequent or rare: allergic reactions to medications, anesthetics, materials, etc.; drug interactions and side effects; excessive bleeding (during the procedure and/or after the procedure); postoperative bruising and discomfort; blood clots anywhere in the body; postoperative infection or bone inflammation; bruising and/or vein inflammation at the site of injections; damage to adjacent teeth, restorations, and/or gum tissue. These are not probable results, they are statistical possibilities.
RESULTS
No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.
TREATMENT CHANGES
My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.
Financial Policy
To provide the highest level of care and service, payment is due at the time services are rendered unless prior financial arrangements have been made.
Patients with dental insurance understand that insurance coverage is a contract between the patient and their insurance provider. As a courtesy, we will assist in submitting claims and processing benefits; however, all charges remain the patient’s responsibility regardless of insurance reimbursement.
Balances outstanding beyond sixty (60) days may be subject to a finance charge of 1.5% per month (18% annually), unless alternative written arrangements have been established and honored.
Treatment estimates are valid for six (6) months from the date of examination and may be subject to change thereafter.
By receiving treatment from this practice, I agree to pay all fees for services rendered either at the time of treatment. If payment is not received within 30 days, or if I designate prior, my credit card on file may be charged for any outstanding balances due.
Cancellation Policy
We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be rescheduled at least 48 hours in advance.
Cancellations made with less than 48 hours notice will incur a $75 fee if the appointment was scheduled with a hygienist, and a $500 fee if the appointment was scheduled with a dentist.
Thank you for being a valued patient and for your understanding and cooperation. The policy will enable us to open otherwise unused appointments to better serve the needs of all patients.
Audio, Video, and Photography Policy
I understand that, as part of my dental care and treatment, The Practice Beverly Hills Boutique Dental may create audio recordings, video recordings, photographs, digital images, radiographs, intraoral scans, and other visual or audio documentation of me, my face, mouth, teeth, gums, and dental treatment (“Recordings”).
I acknowledge and understand that these Recordings may be medically necessary and beneficial for purposes including, but not limited to:
- Diagnosis and treatment planning
- Documentation of dental conditions and procedures
- Communication among healthcare providers and specialists
- Maintenance of accurate dental and legal records
- Quality assurance and case review
- Dental research, education, and professional training
- Practice marketing, advertising, website content, social media, publications, presentations, and other promotional materials
I understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential.
I do not expect compensation, financial or otherwise, for the use of these photographs.