Please take a moment to read carefully the following policies we have in place to help ensure a consistently positive experience for all of our patients.  You may call our office at 210-538-2772 if you have any questions or concerns.

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* 1. Patient Name

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* 2. Patient Date of Birth

Date

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* 3. Payment for Service
Payment in full is due at the time of service.  We accept most major credit cards, Checks, Money Orders or Cash.  We also offer payment plans using CareCredit for six (6) months or twelve (12) months deferred interest.  Our bank charges a fee for deposited checks with insufficient funds, therefore you will be charged $35 for each returned check.

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* 4. Dental Insurance
Your insurance coverage is a contract between you or your employer and the insurance company.  We take pride in providing you with the best dental care based only on your dental needs, not based on your insurance coverage.  We will give you an estimated co-payment amount which is to be paid on the date of service. We will submit claims under one primary dental insurance plan.  Please provide us with the most current primary insurance information prior to each appointment in order for us to give you the best estimate of your benefits.  If for any reason we have not received your insurance carrier’s payment or if your insurance plan does not cover procedures as estimated for any reason, the portion not covered and any remaining balance is your responsibility at 60 days.  In the event that your insurance should pay us after that time, you will be reimbursed.  If it becomes necessary to refer your overdue balance to a 3rd party for collection, you will be responsible for any additional fees or court costs.  By signing this document, I am agreeing to the assignment of benefits from insurance to be payable to A.B. Dental, P.C.

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* 5. Late, Missed or Cancelled Appointments
Quality dental care requires that we set aside an adequate amount of time for our Doctors or Hygienists to complete the planned procedure in the best way possible.  This requires careful planning of our daily schedule in advance.  Patients that make last minute changes to our schedule or run late to an appointment affect our ability to run on schedule with other on-time patients.  For this reason:
  • Prior notice of at least 48 hours (2 business days) is required to cancel or reschedule any appointment.
  • Arriving more than 15 minutes late may require your appointment to be rescheduled or limit our ability to complete all of the scheduled treatment.
  • A missed, cancelled or late appointment fee of $35 will be applied for each patient.
  • Repeated missed, cancelled or late appointments may require that you pre-pay for your appointment.
For patients that have difficulty with scheduling or arriving on time, we will no longer pre-book your appointments.  You will be added to our Priority Reservation List.  Patients on this list will be offered appointments that other patients have given up without proper notice.  When you are contacted, you may choose this appointment time or choose to remain on the list until a more convenient appointment opens up.

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* 6. Confirmation of Appointments
Due to high demand from our loyal patients, it is imperative that our office is able to confirm your appointment status prior to the day of the appointment.  If we are unable to confirm your appointment at least 48 hours (2 business days) prior, your appointment will be cancelled to allow us to accommodate patients waiting to see us.  We use automated text messaging, email and voice calls in addition to personal phone calls in an attempt to confirm your appointment.

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* 7. Unattended Children
We love seeing children as patients!  While your child is having a dental visit, we ask that parents/guardians either remain in the treatment room with their child or stay in the waiting room.  You need to monitor other children if there are multiple children present, or there needs to be an another responsible adult (over the age 18) supervising the other children.  For the wellbeing and safety of your children, the consideration of our dental staff and for the consideration of our other patients, we reserve the right to reschedule patients who do not adhere to the following policies.
  • Any person under the age of 18 must have a parent or legal guardian present at all times in the office.  (No dropping off children).
  • No child under the age of 12 may be left unattended by a parent or legal guardian outside of the treatment room.
  • Only one adult family member may be present in the dental treatment room during a child’s treatment if they so choose.  Other children/siblings may be present only for annual exams so long as they are not disruptive in the treatment room.
  • You may not schedule your own dental treatment with a baby or child under the age of 12 present in the dental treatment room or in the office.  Another adult parent or guardian must be present to monitor them.
Unlike most dental offices, we encourage a parent to be present in the treatment room for all children.  However, we reserve the right to ask a parent to wait in the reception area with any children not in the dental chair for treatment if multiple children are present or if they become disruptive to care or disturb other patients.

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* 8. Do you give permission for Doctors and staff of Alamo Ranch Dental to discuss your dental care with other family members?

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* 9. In order to utilize your insurance benefits and/or provide your optimum dental care, we must share your protected patient information with your insurance provider.  In addition, we will share your information with any specialists we refer you to.  Please take a moment to review our full HIPAA policy HERE and check both boxes below.

** It is your legal option to not sign this acknowledgement of the above policies, however if we do not have this signed acknowledgement from you, we will not be able to provide you with our services.**

By signing below, I acknowledge and agree to the above policies for myself and all family members under 18 or under my legal care.

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* 10. Please Type your First & Last Name and check the box below.

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