Wilson Dental Office Policies
Welcome to our practice! The following policies will help you understand our processes and procedures. Please initial each section and sign and date at the end.

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INFORMED CONSENT/TREATMENT AUTHORIZATION By initialing here, you acknowledge that you have received copies of the Privacy Notices, Office Policies, and Informed Consent for Treatment of Wilson Dental and its providers and were given the opportunity to answer clarifying questions to your satisfaction. After weighing the benefits and risks, you hereby give your consent for evaluation and treatment by Wilson Dental. INITIAL BELOW *
INSURANCE BENEFITS REASSIGNMENT AUTHORIZATION AND REIMBURSEMENT If you have a dental health insurance policy, it may provide full or partial dental health coverage. We will bill your insurance directly for services rendered; however, you are responsible for full payment of the service fees. We are required to submit this information on your behalf if you choose to obtain insurance reimbursement. In cases where your insurance does not pay for your service, you will be billed and will be expected to pay the amount that the insurance company was contracted to pay on your behalf. By initialing here, you agree to assign your insurance benefits (current and future), if any, to Wilson Dental otherwise payable to you for services rendered. You further authorize the use of your signature on all insurance submissions. INITIAL BELOW: *
CANCELLATIONS AND NO-SHOW POLICY  Once your appointment is scheduled, you will be expected to attend unless you provide at least 24 hours advanced notice of cancellation. If you do not provide at least 24 hours notice, or fail to show you will be responsible for a $30 no-show/late cancellation charge and if you fail to show for a scheduled FOLLOW-UP appointment, you will be responsible for a no-show/late cancellation. Please Note: this fee must be paid before future appointments will be scheduled or medication refills will be given. If you arrive late and miss half of your scheduled appointment time, you will be rescheduled, and a late cancellation charge or no show fee may apply. INITIAL BELOW: *
EXCESSIVE NO SHOWS OR LATE CANCELLATIONS    Consistency is the key to improving and maintaining your dental health. To this end, after three (3) missed appointments without notification, or after three (3) late cancellations (less than 24-hours notice) of your appointments, you could be dismissed from our practice. A certified letter will be sent notifying you of this decision, in the unfortunate and unlikely event that this may occur. INITIAL BELOW *
BILLING AND PAYMENTS   You are expected to pay appropriate co-payments, deductibles, and account balances for each visit at the time of the appointment. We accept cash, checks, and credit cards for payment. If your account has payment overdue for over 60 days, we have the option of referring your account to a collection agency and closing your account with our office. INITIAL BELOW *
By typing my name  below, I indicate that I have read the above policies and fees and agree to be held by them. I was given the opportunity to ask clarifying questions to my satisfaction. If the parent of a minor, by signing below, I indicate that I am the custodial parent and am authorized to make final treatment decisions on my child’s behalf. *
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