To help us with a proper diagnosis and appropriate treatment plan, have your partner, if applicable and available, fill out this questionnaire regarding your sleep habits. This information is vitally important for Dr. Clinton to best evaluate your current condition. This is to be filled out by the patient's partner
How likely is your partner to doze off or fall asleep in the following situations, in contrast to just feeling tired?
Use the following scale and choose the most appropriate number for each situation:
0 = Would never doze
1 = Slight chance
2 = Moderate chance of dozing
3 = High chance of dozing
Please take a moment to read our office policies and feel free to ask any questions you may have.
Consent For Treatment
I hereby authorize Sydenham Family Dental and designated staff to take x-rays, study models, photographs, electro-diagnostic studies and other diagnostic aids mutually agreed upon and deemed appropriate to make a thorough diagnosis
Upon such diagnosis, I authorize Sydenham Family Dental and staff to perform all recommended treatment mutually agreed upon by me and to employ such professional assistance as required to provide proper care.
I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I authorize the release of a full report of examination findings, diagnosis, treatment program and ongoing progress report to any referring dentist, physician, chiropractor or other health care professionals as indicated previously. I additionally authorize the release of any medical information to insurance companies for legal documentation to process predeterminations and claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.
Payment is expected the day of your procedure as outlined verbally and/or in the written financial arrangement. We accept cash, Master Card/Visa Debit. For our patients carrying medical insurance, we do not accept assignment of benefits. However, we are happy to assist you with your insurance billing as a courtesy, though financial responsibility lies with you. Please ask our Patient Coordinators about your insurance issues
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received as agreed, I understand that a late charge of 1.5% on monthly balances will be added to my account and my account may be turned over for legal collection of any overdue amount. Our goal is to eliminate "billing surprises" so let us help you plan your treatment carefully by addressing your financial concerns before treatment begins.
Should you need to cancel an appointment, we ask that you notify our office at least 24 business hours in advance. If you fail to cancel your appointment appropriately or do not show up for your scheduled appointment, you will be charged a broken appointment fee of $100
I have read and understand the Sydenham Family Dental Consent for Treatment, Financial and Appointment policies. I have had all of my questions regarding these issues answered by a Patient Coordinator and agree to abide by these policies.