530 Chauvet DrPittsburgh, PA 15136Tel: (412) 876-8003E-Mail: email@example.com
Our goal is to provide the highest quality dental care to our patients while also respecting their schedule. In fairness to other patients, and the office staff, we require advanced notice when changing or cancelling an appointment. When you schedule an appointment, we reserve that time and prepare in anticipation of serving you. If you should need to reschedule, we kindly request that you contact us at least 48 hours prior to your originally scheduled appointment. We understand that conflicts arise; however, failing your appointment or canceling without adequate notice more than once may result in a charge. Patients who continue to no-show and/or cancel without notice may be dismissed from the practice and asked to find another dentist.
Any patient who is late may be considered a “no show” for their appointment and may need to be rescheduled.
We require payment in full for all services rendered at the time of visit. We accept all major credit and debit cards, cash, and checks.
If you have dental insurance, we will be happy to file your claim. Deductibles and estimated co-pays are due at time of service.
The signatory below is responsible for any balance not paid by the insurance company. We encourage you to check with your insurance company regarding specific coverage and limitations.
Accounts 90 days overdue are subject to late fees and collections; agency fees and other charges may apply.
Treatment Consent & Disclosure:
We invite you to discuss with us any questions regarding your dental care. The best dental care is based on a friendly, mutual understanding between the provider and patient. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. We will make an effort to anticipate any changes in the treatment plan and advise you at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible.
Please note that Terrific Teeth uses only composite resin fillings. Some insurance policies provide alternate benefits in lieu of composite resin fillings which places the financial responsibility back on the member.
Being the parent or guardian, I do voluntarily consent to the performances of examinations, diagnostic procedures (including x-rays), fluoride treatments, sealants, extractions, resin fillings, or stainless steel crowns for my child. I understand that this consent will remain in effect for as long as the patient remains an active patient with Terrific Teeth. I understand that I may obtain a notice of Privacy Practice upon request.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize assignment of my insurance benefits directly to the provider, and authorize the provider to release any information required to process insurance claims. I understand the above information and certify this form was completed to the best of my knowledge, and understand it is my responsibility to inform this office of any changes to the information I have provided.
I have read, understand and agree to the above policy.