Form

Appointment Policy

Sparks Dentistry is committed to providing you with the best possible care. As your dental provider, we want to help you understand and plan for your oral health. However, it is difficult for us to provide quality care when patients do not attend scheduled appointments.

Patient Name

Date Of Birth

Wait List
We do our best to have our patients scheduled in a timely fashion. In instances where you cannot get scheduled within your preferred timeframe, we are happy to place you on a wait list. When patients cancel, we send a text message to patients on our wait list with the date and time of the appointment. Appointments are filled on a first-come, first-serve basis.

Being placed on the wait list is not a guarantee of an appointment. To ensure that all our patients receive care, we recommend scheduling an appointment, even if it is not within your preferred timeframe, in case sooner appointments do not become available.

Cancellations
We understand that patients are sometimes unable to make their previously scheduled appointments. However, failing to give 24-hour notice makes it difficult, if not impossible, for us to offer cancelled appointment slots to other patients in need of treatment. Frequent cancellations without 24-hour notice or failure to show up to scheduled appointments may result in fees or dismissal from the practice.

· First Last-minute Cancellation or No-Show: No fee
· Additional Last-minute Cancellation or No-Show: $45 for cleanings

$100 for restoration/extractions

Patients may be dismissed from the practice following three last-minute cancellations or no-shows to an appointment within 18 months.

All last-minute cancellations or no-show fees MUST be paid in full prior to rescheduling the cancelled appointment.

Delinquent Accounts
We send statements to all patients with balances monthly. If balances are not paid after 90 days, accounts may be sent to a third-party collection agency or otherwise dismissed from the practice and all future appointments may be cancelled.

Patient/Legal Guardian Signature

Date