Office Policies

It is our office policy to take a full series of x-rays on every adult new patient. This helps us to treat & diagnose our patients.

AUTHORIZE OR DECLINE

I ________________ AUTHORIZE Farmington Family Dental to take a complete series of x-rays. I have not had a series of x-rays in the last 5 years. I understand that if my insurance company denies payment for these x-rays, I am responsible for the balance.

I ________________ DECLINE the complete series of x-rays suggested by Farmington Family Dental. I have had a complete series of x-rays in the last 5 years. You can contact Dr. ____________ _ at ____________ to obtain a copy for my records.

First Name

Last Name

Email Address

**If Declined, please provide the following information.

Name of Doctor

Doctor Contact

Our office does it's best to confirm your dental benefits for you with the information you provide. It is ultimately your responsibility to know and understand your benefits as well as inform us to any changes that may occur.

When appointments are scheduled please understand that we have reserved that time on our schedule specifically for you. If you need to cancel, we ask that you give us a 24 hour notice. Any missed or appointments that are cancelled last minute can be subject to a $35.00 charge.

Electronic Signature Aggreement

I ACCEPT. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

Digital Signature

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