PATIENT CONSENT

I consent to be a patient of Bozeman Denture Center and agree to a radiographic and clinical examination. I also understand and consent to the following:

During the course of treatment, I may undergo procedures including fixed and removable prosthodontics (bridges and dentures), implant dentistry, restorative dentistry, oral pathology, and radiography.

I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to communication with my other medical practitioners to inquire about any aspect of my health history.

No guarantees can be made about treatment outcomes, restorations longevity, or prognosis. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

I understand that photos may need to be taken for diagnostic purposes and these photos will not be used for any other manner without additional consent.

I understand that payment is expected at the time of service unless other financial arrangements have been made. My insurance will be submitted as a courtesy and I am responsible for the patient portion at the time of service. I understand that the patient portion is an insurance estimate and there may be an additional remaining balance that I will be responsible for once my insurance has made payment. Should the account be referred to a collection agency or attorney for collection, the undersigned shall pay all attorneys fee and collection expenses.

I understand that a 24 hour notice is required to cancel or reschedule my appointment. We reserve the right to charge a fee for broken appointments or ones that are not cancelled beforehand within a reasonable time frame. If repeated “No-Shows” occur, you will be discharged from care. If an appointment is not confirmed 24 hours in advance I understand that my appointment will be canceled or rescheduled.

I am welcome to ask questions about any aspects of my care and will request information if I am confused or need more information. My treatment plan my change at any time and I am responsible for clarifying any aspects of my treatment that I am unsure about. I do have the right to refuse any treatment.