Office Policies

Thank you for choosing us as your child’s pediatric dentist. We are committed to the successful treatment of your child’s dental needs. Prior to any treatment being rendered, we require that you acknowledge in writing your receipt of this document and your understanding and agreement with the below policies.

Appointment Policy:

  1. We require at least 24 hours notification for appointment rescheduling or cancellation. This policy allows us to offer the appointment time to another child.
  2. Two (2) cancelled appointments with less than 24 hours notice or two (2) missed appointments will prevent further scheduling by our office
  3. We require verbal confirmation or electronic confirmation via text or email to hold the patient's appointment.
  4. Our office is very busy. We may not be able to see a patient who arrives 15 minutes or more late, and should the patient not be treated on the date of their appointment, it will be counted as a missed appointment. If a patient arrives more than 15 minutes late, the legal guardian has the following options:
    • Option 1: Reschedule the appointment.
    • Option 2: Wait to be filled in during an opening on the same day. *There are no guarantees on this option.*
  5. Scheduling family members together is a courtesy we extend to our patients. However, patients from the same family who have missed a family appointment or cancelled a family appointment with less than 24 hours notice will not be allowed to schedule appointments together again.
  6. A legal guardian, or an individual previously authorized by the legal guardian in writing, must accompany the patient to each dental visit and remain at our office throughout the entire appointment.
  7. We understand emergencies happen, especially with children. We are happy to see our patients on an emergency basis, but we do require an appointment for an emergency. Please call us before coming to the office and we will fill the patient in as soon as possible. However, if the patient does not show for an emergency appointment, he/she will not be rescheduled as an emergency. The patient will be rescheduled at our first available appointment.
  8. If the dentist(s) recommends the patient undergo outpatient dental surgery but the patient’s legal guardian chooses to forgo the recommended surgery the patient will be dismissed from the practice. We will see the patient on an emergency basis only for one month from the date of the surgery approval release

Financial Policy:

Our staff is happy to assist you with your insurance questions. As a courtesy, we will file the patient’s insurance claim. Please understand that we do not have a contract with the insurance company, only the insured does. It is therefore the insured’s responsibility to correct any problem of payment with the insurance company. We are not responsible for what benefits are or are not paid on a claim. We can only assist you in estimating your portion of the cost of treatment. We are not responsible for any errors in filing your claim.

If a patient does not have dental insurance or is not eligible for dental insurance, then payment in full is required on the day of service. If a patient is retro-activated with their insurance, then our office will reimburse the insured once our office has been paid by the insurance company.

When patients are scheduled for operative appointments (i.e. sealants, fillings, nitrous oxide, etc.) we will estimate the patient’s financial portion and require the estimated amount to be paid on the day of service. We accept cash, check, or credit card (Visa or MasterCard). There will be a $35 fee if your check is returned.

Medical Photography Release/Approval:

Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office is dedicated to the use of the most advanced technologies available in giving and documenting your child’s medical and dental care. To this end, we have invested in electronic medical records. This means that all items traditionally maintained in a paper format will be obtained, stored, and cataloged digitally. This record will also include digital photographs of your child(ren) for identification by our licensed professionals and staff. Any lesions, procedures, or other items which may be documented visually will also be stored and reproduced in this manner.

I hereby authorize the licensed professionals and staff of Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office to obtain and reproduce photographs of my child(ren)’s likeness(es) for purposes of medical records. I also approve the use and reproduction of clinical photos for referral, coding, charting, marketing, advertising, and educational purposes.

By executing below, I acknowledge I have read and understand the Office Policies for Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office and will comply with same.

Patient Name (PRINT)
Date of Birth:
Date:
Email:
Cell Phone:
Legal Guardian Name (PRINT):
Legal Guardian Signature

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