Patient Agreements

Patient Agreements

Our Mission

In our dental practice, we strive to serve the needs of you, our valued patients, to the best of our ability. We aim to provide the highest quality dental care in a relaxed and comfortable environment. We understand that you have a choice in dental care, and we thank you for choosing our office.​​​​​​​
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Name*

Confirmation

It is imperative that you confirm your scheduled appointment with our office at least 2 business days prior to your appointment. Your appointment time is reserved for you. We do not double book our providers. Confirming your appointment allows us to provide quality care and appointment times for all of our patients. You may reach us during office hours, leave a voice mail message after hours, or send an email to adh.office@adhaz.com. If we have not heard from you, we will make every effort to contact you at the numbers you have provided us. Unconfirmed appointments are subject to cancellation.
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Arrival

We understand that your time is limited and valuable. We will make every effort to see you at your appointed time. For this reason, we ask you to be ready for treatment at your appointed time. We understand that unforeseen circumstances can cause delays in your arrival. In order to provide you with the necessary time to complete your treatment, we may ask that you reschedule any appointment that we cannot complete during your scheduled time. If you are more than 15 minutes late for your appointment, we may not be able to see you and you will be charged a missed appointment fee if your appointment needs to be canceled due to your tardiness.
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Minors

Children under the age of 18 must be accompanied by a parent or legal guardian for ALL dental visits in our office. Future dental treatment will not be performed without prior arrangements between our office and a consenting adult. If a minor child arrives unattended for dental treatment or cleaning appointments, the appointment will be rescheduled.
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Length of Appointment

In order to serve you with our undivided attention, we schedule your dental treatment as a block of time. This allows us to focus only on you and assures you that you will be finished with your dental appointment on time. For any appointment longer than 60 minutes, we ask for one-half of your payment when the appointment is made and the second half at your scheduled appointment
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Dental Insurance​​​​​​​

As a professional courtesy, we will submit your dental insurance claims. While we will assist you in obtaining benefit information, we are not privileged with all of the detailed provisions of your particular plan. All estimates provided in our office are based on general benefit information. Questions regarding your specific dental benefits should be directed to your insurance company, to include if you are in network or out of network with your dental insurance at this office.

You are ultimately responsible for all charges incurred in our office regardless of dental insurance benefits and procedures will not be written off due to non-coverage by your insurance. You will receive a statement from our office for any unpaid balances and any unpaid balance over 30 days will incur finance charges at 18%APR monthly and will be subject to being sent to a collections agency or Small Claims Court after 90 days.

E-Signature

Date Signed