Patient Agreement

Your care

I consent to an examination, x-rays and cleaning as needed. Any further treatment will be explained to me, including its cost, before it begins, and I may accept or decline it.

I will give the practice my full medical history and a list of my medications, and I will tell the practice about any changes.

Appointments

Each appointment time is reserved for me. If I need to cancel or reschedule, I will call as early as possible so the time can be offered to another patient. If I arrive late, the visit may need to be shortened or rebooked so that other patients are not kept waiting.

Fees and payment

I am responsible for the fees for my treatment, including any amount my insurance does not pay. I will receive an estimate before treatment begins. If the treatment I need changes, the fee may change, and the practice will discuss this with me first.

Payment for my share of the fee is due when treatment is provided, unless I have arranged a payment plan or financing with the practice in advance.

Insurance

The practice will verify my benefits and file claims with my insurance on my behalf. My insurance plan is a contract between me and my insurer, so the practice cannot guarantee what the plan will pay. I will tell the practice about any change to my insurance.

Communication and privacy

I agree that Next Generation Dental may contact me by phone, text message and email about appointments, treatment and billing. Message and data rates may apply, and I can ask the practice to stop text messages at any time.

I have been offered a copy of the practice's Notice of Privacy Practices.

Agreement

• I have read this agreement and had the chance to ask questions.
• I understand my financial responsibility for treatment.
• I agree to be contacted as described above.