1. X-Rays and Photos. The initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan. Modern dental x-ray equipment is extremely low-dose radiation. Without these x-rays, we cannot do a complete exam of the entire mouth and jaw. We may also take photos of our patients as part of their permanent record.

2. Medication Administration. I have been informed and understand that anesthetics, analgesics and antibiotics and other medications used in dentistry can cause allergic reactions including redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock. They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand that antibiotics can reduce the effectiveness of oral contraceptives. I have informed the Dentist of any known drug allergies.

3. Dental Prophylaxis (Cleaning). I understand the treatment involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal disease. In case of diagnosis of periodontal disease, the dentist will discuss further treatment options with the patient.

4. Sealants. By placing a resin material in the pits and fissures of back teeth it helps lower the chance of getting tooth decay on those surfaces. Risks include loosening or dislodging — sealants are not permanent. Leakage or decay: inadequate home care and diet can still overpower the protective forces of a sealant.

5. Specific Problem Examination. In the event that a patient requests only a specific problem to be addressed, this is considered a problem focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive examination will not be done.

6. Changes in Treatment Plan. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on teeth that could not be discovered during examination. I do authorize the performance of additional procedures and changes of planned procedures if, in the judgment of the doctor, this will be necessary to improve my safety and result.

7. Complications. Complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics, anesthetics, and injections include (but are not limited to) swelling, sensitivity, bleeding, pain, infection, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth. Although extremely rare, such conditions as Bell's Palsy and Trigeminal Neuralgia may occur.

We do require a 24 hour notice for any changes or cancellations to your appointment. This allows us the time in our schedule to be filled by another patient who may have been waiting for this appointment time.

A fee will be charged to your account for not honoring this policy. There is a $25 charge for each 1/2 hour of scheduled appointment time missed. For example, if you had an hour appointment scheduled, the charge is $50.

We reserve time in our schedule for you in order to accommodate your busy schedule. We ask that you give us the same consideration when needing to change or cancel your appointment.

Medicaid/CHIP Patients: Our office is bound to notify MCNA & DENTAQUEST of any canceled appointments or no shows. If you cancel or do not attend your appointment, our system notifies them automatically.

I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practices.

Smilux Dental is committed to protecting your privacy. The Notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

We typically use or share your health information to treat you, to bill for our services, and to run our office.

You have the right to get an electronic or paper copy of your medical record, ask us to correct it, request confidential communications, request limits on what we use and share, and get a list (accounting) of the times we have shared your health information for the prior six years.

Please note: it is your right to refuse to sign this Acknowledgement.

Although we file claims for you as a courtesy, your dental insurance policy is a contract between you, your employer, and your insurance company. We are not a party to that contract.

Your treatment plan is individually tailored and is not based on your dental insurance benefits or lack of benefits.

Not all services are covered benefits in all contracts. It is your responsibility to thoroughly understand the coverage and exceptions to your particular policy.

I understand that the following services are not covered by my insurance and will be my responsibility to pay in full: LAB, Endir, MEDC, MEDCH, AREST, Liner, DESEN, D9910, D9630, D7953.

Your claim will be filed immediately, and benefits are expected to be paid within 30-45 days. If the claim is not cleared by your carrier in 60 days, the unpaid portion will automatically become “self-pay” and a statement will be issued to you.

Refund Policy. You may request a refund for any pre-paid treatment that has not been started at any time. Refunds are processed back to the original form of payment, except cash payments which are refunded by check, and may take 45-90 business days. All services once rendered are final, and payment for any treatment once started is non-refundable. Please inform us of any needed modifications within 60 days of the original date of service.

Authorization for insurance benefits to be paid to the office. I hereby authorize my insurance benefits to be paid directly to Smilux Dental. I realize that I am responsible to pay for any deductible amount(s), my co-insurance portion and for any non-covered services. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as the original.