Our office has set many goals, and one of our main goals is to be more responsive to your scheduling needs. We value our patients' time and expect the same in return. One area of scheduling that causes us concern is a Broken Appointment. A broken appointment is defined as not showing up to a scheduled appointment, a 'late cancellation' (cancelling within 24 hours of your appointment), or being 10 minutes tardy. In order to schedule properly and minimize the amount of time between appointment dates, we ask that all our patients keep their appointment times. We call, text, and/or email a week prior to your appointment and the day of to remind you. We ask that you call or text us back to confirm your appointment. We have found that this helps reinforce your ability to remember that you have an appointment. Also, with proper notice, we are able to schedule patients on our waiting list into the cancelled appointment. Our Broken Appointment policy is as follows: First offense: you will be reminded of our policySecond offense: you will be charged as follows:25% of total fee for major procedures (crowns, bridges, root canals, implants ect.)50% of total fee for basic procedures (cleanings, fillings, impressions, denture ect.) 3. Third Offense: Dismissal from the practice We understand that unforeseen circumstances and emergencies may arise. When these situations occur, we ask that you contact our office as soon as you are able. We will review the occurrence and decide whether a broken appointment is warranted. We thank you in advance for your continued commitment to the quality of care we provide and we look forward to working together in the coming years.
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 of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.