I consent to be a patient at the above-named office in Oakland, California and agree to a radiographic (x-rays) examination, a clinical dental examination and prophy (dental cleaning). I also understand and consent to the following:
1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. I acknowledge that Newbury Dental associates and employees will make every effort to explain the nature and purpose of proposed procedures and alternative options, but it is the patient responsibility to ask questions and elect for treatment.
2. Once I am informed of recommended treatments and agree to undertake them, I authorize the dentists, hygienists and dental assistants at Newbury Dental to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have legal responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical or chemical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.
3. I voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results which may or may not be achieved for my benefit or the benefit of my minor child or ward. I understand that any branch of medicine, including dentistry, can involve unanticipated results.
4. I have the right to refuse any specific dental treatment, and I voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with foregoing any dental diagnostic or recommended treatment procedure.
5. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, and temporary or rarely, permanent numbness, and muscle soreness. I understand that it is possible for needles to break during the administration of local anesthetic and that surgical recovery of the needle may be necessary.
6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
7. I understand that Newbury Dental requests 48 hours notice for canceling any appointment. If I dont notify Newbury Dental of a cancellation at least 48 hours in advance of the appointment, I will be subject to a $75 appointment cancellation fee. If procedures performed during an appointment cost more than $4,000, I agree to paying a 10% down payment for those procedures, at the time of booking of that appointment.
8. Payment may be made in cash, check, or by credit card. I understand that my balance for services is due on the day the treatment is rendered. If I am an insured patient, I am responsible for the patient portion of the contracted insurance fees on the day the treatment is rendered as well. The amount of reimbursement is determined by the insurance carrier and the numbers I am presented on the day of treatment are estimates. If the final reimbursement or patient responsibility amounts change, I may be responsible for additional payment to Newbury Dental. If financing is offered and accepted by me through a third party or through Newbury Dental, I am subject to the terms of the financing agreement and will make payments to Newbury Dental or the third party in accordance and at the times specified in the agreement. A $25 processing fee will be charged for a returned check.