All patients who provide information to and receive services from Signature Dental will be asked to sign our Consent form with the terms and conditions as indicated below.

Consent for Services

  • I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
  • I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.
  • I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.
  • To the best of my knowledge, all of the information provided is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Financial and Insurance Policies Consent

  • As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.
  • A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
  • I understand that any fee estimate for this dental care can only be extended for a period of 90 days from the date of the patient examination.
  • In consideration for the professional services rendered to be by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
  • Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
  • I authorize the payment from my insurance carrier to be submitted directly to the dentist or dental practice and be applied directly to any outstanding balance on my account.
  • I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any) whether or not paid by insurance.
  • I grant my permission to you or your assignee to telephone me to discuss this statement or my treatment.
  • I authorize the use of this electronic signature on all submissions.
  • I have read the above conditions of treatment and payment and agree to their content.

HIPPA Acknowledgement

  • I understand that I may inspect or copy the protected health information described by this authorization.
  • I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.
  • I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
  • By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPPA Disclosure Form.

Consent for Internet Communications

  • I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information, and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me, and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or any other need to deactivate my ID due to security concerns.
  • I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THE SITE OR THE SERVICES.
  • I have read the information above regarding the secured uploading of patient information to the web site for the dental practice and grant the dental practice permission to securely upload my patient information to the web site.

Consent for Text Messaging

Our text messaging service is provided “as is” on a “best efforts” basis. Signature Dental utilizes underlying messaging application service providers and carriers (whether fixed or wireless) to deliver your text messages to intended recipients. Note that the text messaging service may not be available on all equipment, or through all wireless carriers, and not all functionalities of the text messaging service are available through all wireless carriers. The text messaging service is subject to transmission limitations or interruptions. Intended recipients may be reliant on carriers to receive your text messages. Zoom cannot and does not guarantee that your text messages or alerts will be delivered or that delivery will meet any quality of service. Signature Dental does not guarantee that alerts will be delivered and will not be liable for delayed or undelivered messages.

The Company may use Personal Data for the following purposes:

  • To provide and maintain our Service , including to monitor the usage of our Service.
  • To contact You: To contact You by email, telephone calls, SMS, or other equivalent forms of electronic communication, such as a mobile application’s push notifications regarding updates or informative communications related to the functionalities, products or contracted services, including the security updates, when necessary or reasonable for their implementation.
  • To attend and manage Your requests to Us.
  • Message sending frequency may vary, and data rates may apply.