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Mark E Lawton D.D.S., P.A.
7038 Antoine Dr
7038 Antoine Dr
Houston, Texas 77088
Houston, Texas 77088
Missed Appointment Policy
PATIENT HIPAA AWARENESS & Notice of Privacy Practices
With my permission, Mark E. Lawton D.D.S., P.A. may use and disclose protected health
information (PHI) about me to carry out treatment, payment and healthcare operations
(TPO). Please refer to Mark E. Lawton D.D.S., P.A. Notice of Privacy Practices for a more
complete description of such use and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent.
Mark E. Lawton D.D.S., P.A. reserves the right to revise its Notice of Privacy Practices at
anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written
request to the Privacy Officer.
With my permission, the office of Mark. E. Lawton D.D.S., P.A. may call my home or other
designated locations and leave a message on voice mail or in person in reference to any
items that assist the practice in carrying out TPO, such as appointment reminders,
insurance items and any call pertaining to my clinical care, including laboratory results.
With my permission, any items that assist the practice in carrying out TPO, such as
reminder cards and patient statements may be mailed to my home or other designated
location. I have the right to request that Mark E. Lawton D.D.S., P.A. restrict how it uses
or discloses my PHI to carry out TPO. However, the practice is not required to agree to
my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am allowing Mark E. Lawton D.D.S., P.A. to use and disclose my PHI
for TPO.
We respect the importance of your time and work very hard to schedule appointments
which accommodate the busy scheduling needs of all our patients. In return, we ask that
patients make every effort not to change reserved dental appointments. Broken and
missed appointments create scheduling problems for other patients as well as the
practice.
If emergency circumstances prevent you from keeping an appointment we certainly
understand, all we ask is that you call us immediately so we can try to accommodate
another patient.
Ultimately as with any appointment, it is your responsibility to keep track of your
appointments. We ask you to provide us with a minimum of forty-eight hours notice.
Failure to do so may result in a cancellation/missed appointment fee of $35.00 per hour
of appointment time reserved for you.
We provide as a courtesy, reminder cards that are mailed for dental hygiene
appointments. We also make reminder calls to our patients one business day prior to
appointments. This effort shows our commitment to all of our patients and the
importance of their health.
If you have any questions, please do not hesitate to contact us. We sincerely appreciate
your understanding and cooperation in this matter.
By signing this form, I acknowledge that I have read this statement and agree to the
contents.
By signing this form, I acknowledge that I have read this statement and agree to the
contents.
Signature of patient, parent, or guardian (responsible party)
Signature: __________________________________
Date: ___________
Mark E Lawton D.D.S., P.A.
Signature: ________________________________
Date: _____________
Informed Consent for Dental Treatment
Patient Name:_____________________________________________________
I hereby authorize Mark E. Lawton and his licensed providers to treat me or the or the person under my care (I am the legal guardian, or close relative) with the
following dental (if or when needed) : prophylaxis (dental cleaning), restorations (fillings), crowns, fixed bridgework, full or partial removable dentures, cosmetic
dentistry, extractions, non-surgical and/or surgical treatment of gums, root canals, dental implants, bone grafting, all emergency services and any other
treatment the dentist considers necessary to create better health for my mouth.
Dentistry is not an exact science and reputable practitioner cannot properly guarantee results. Despite the most diligent care and precaution, unanticipated
complications or unintended results, although rare, may occur. A treatment plan is based on the best evidence available during the examination. There is no
guarantee that this plan will not change. During treatment, it may be necessary to change or add procedures because of conditions that were not evident during
examination, but were found during the course of treatment. For example, root canal treatment may be needed during routine restorative procedures. Any
change in treatment plan may result in additional fees.
Guarantee and assurances cannot be made by anyone regarding the dental treatment which you have requested and authorized. It is essential that you keep
your appointments and cooperate in your treatment to help insure the best possible results.
The licensed provider at Mark E. Lawton’s has fully explained to me the nature and purpose of the procedure(s), and has also explained the expected benefits
and potential risks(from known to unknown causes) of the treatment. I have been given alternatives to the treatment, the
risks and benefits of the alternatives and the consequences of having treatment withheld. I have been given the opportunity to ask questions, and all of my
questions have been answered fully and satisfactory.
I understand that during treatment, unforeseen conditions may arise which may necessitate procedures different from those discussed prior to treatment. I
therefore consent to the performance of any additional treatment which the dentist considers necessary.
I consent to the use of local anesthetic, antibiotics and pain medication, which have been explained of all potential risks associated with their use. I understand
that there is a slight element of risk involved with the use of local anesthesia or the use of any drug. These risks may include allergic reaction, aspirations, pain,
cardiac arrest, discoloration and injury to blood vessels and nerves which may be caused by injections of any medication or drug. Injection of a local anesthetic
can at times although rarely, cause temporary or permanent nerve damage.
Signature______________________________
Date:_________________________________
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