New Patient Packet here

Comments

Transcription

New Patient Packet here
__________________________________________________________
Welcome
We are pleased that you have selected our practice to provide treatment for your current medical and
dental needs.
A consultation fee is charged for you first visit, which may include:
!
!
!
!
!
!
Oral examination
Review of medical history
Diagnosis (clinical and radiographic)
Surgical and anesthesia options
Discussion of what to expect during the postoperative recuperation period
Discussion of risks and complications associated with treatment or non-treatment
FEES FOR CONSULTATION AND X-RAYS ARE BILLED TO YOUR INSURANCE. IF YOU ARE
UN-INSURED THESE FEES ARE DUE ON THE DAY OF CONSULTATION. An insurance
company’s authorization for consultation and x-rays does not guarantee their payment. Ultimately, you, as
the patient, are responsible for any uncovered charges. If there is a question with your coverage, please
feel free to verify your coverage with your provider prior to consultation.
Please understand that your surgery appointment is not a routine office appointment and must be
following with the following cancellation policy:
A 10% fee of the estimated charges (minimum of $250) will be assessed if:
1. You do not follow the attached pre-operative instructions
2. You do not provide 2 business days’ notice if you are unable to keep your appointment
3. You do not show up for your appointment
4. You are over ten minutes late for your appointment
5. Payment is not received for your appointment
The above will need to be paid prior to rescheduling the appointment. Cancellations can be made during
normal business hours Monday-Thursday 9:00am-4:00pm. We do not accept cancellations via our
answering service.
Thank you for allowing us to participate in your care!
Signature: _____________________________
__________________________________________________________
10103 Ridgegate Pkwy Suite 214 Lonetree, CO 80124 Ph (303)768-8222 F(303225-4733
www.catalanooralsurgery.com
*Member, American College of Oral and Maxillofacial Surgeons *Member, American Association of Oral and Maxillofacial Surgeons
CANCELLATION POLICY
Please understand that your surgery appointment is NOT a
routine office appointment and MUST be followed with the
following cancellation policy:
A 10% Fee of the estimated charges, with a $250 minimum
(whichever is greater) will be charged if:
1) You do not follow the attached pre-operative instructions
2) You do not provide 48 business hours’ notice if you are
unable to keep your appointment.
3) You do not show up for your appointment.
4) You are over 10 minutes late for your appointment.
5) Payment has not been received for your appointment.
Please note that the above will also be subject to the
rescheduling of your appointment and any additional
charges will need to be paid prior to your appointment
booking.
Cancellations MUST be made during normal business hours
Monday – Thursday 8:30 am - 4:00 pm. We do NOT accept
cancellations via our answering service.
X____________________________
(Signature patient/ responsible party)
X____/_____/_____
(Date)

Similar documents