Patient Agreement Form

Lateness Policy

If a patient is more than 15 minutes late to their Hygiene appointment, they can only receive a limited appointment which consists of x-rays and an exam by the doctor. A cleaning will not be performed as there will not be sufficient time for a thorough cleaning and we run the risk of running behind for the next patient. If a patient is late for their Dr. Appointment, the patient will need to reschedule and a $50 reservation fee will be required for the next appointment.

Lateness Consent(Required)

I've read and agree to the lateness policy

Missed Appointment Policy

We require 24 hour notice if you need to reschedule your appointment. If you cancel under the required time, we are happy to reschedule you but to do so will require a $50.00 reservation deposit to hold your next appointment. This deposit will be credited towards your next appointment, as long as you make that appointment. If you fail that appointment, then your deposit is charged as a missed appointment fee. If you fail two consecutive appointments, we will assume that you have found dental care elsewhere.

Missed Appointment Policy Consent(Required)

I've read and agree to the missed appointment policy

Children Policy

Children under the age of 18 years old must have a parent/guardian over the age of 18 present for the entire duration of the appointment. Children in the waiting area need adult supervision at all times.

Children Policy Consent(Required)

I've read and agree to the children policy

X-Rays Policy

Pregnant patients are exempt from having x-rays. Others who refuse x-rays cannot continue treatment by your dental care provider. X-rays are a diagnostic tool to detect caries and decay only portrayed in radiographs and cannot be seen by the naked eye. Our practice is committed in providing accurate and exceptional care for your dental needs. We simply cannot give the best diagnosis to treat an affected area without the use of x-rays and will discontinue dental treatment if there is the refusal of dental diagnostic radiographs.

Refusal of X-rays Policy Consent(Required)

I've read and agree to the refusal of x-rays policy

Insurance Verification Policy

If we are unable to verify insurance coverage or your benefits have changed, you must let us know at least 24 hours prior to your appointment. If we are unable to verify your coverage, you will be expected to pay for treatment in full.

Insurance Verification Policy Consent(Required)

I've read and agree to the insurance verification policy

Collections Policy

Co-pays are due at the time of your appointment. These are estimated co-pays. All balances are to be paid within 30 days after receiving statement. Any balance not paid after 90 days will be sent to a collection agency where a $30 fee will be applied.

Collections Policy Consent(Required)

I've read and agree to the collections policy

Name(Required)

First Last

Email(Required)

Patient Signature(Required)

Date(Required)

About | Services | Patients | Contact

Phone: (302) 314-2906
Email: office@smilebritedelaware.com

Smile Brite Dental Care
300 Biddle Ave., Suite 204
Newark, DE 19702
Get Directions
Newark Office | Sitemap