Patient Rights
Access to Care
- Receive quality dental care regardless of race, religion, gender, or national origin
- Be treated with respect and dignity by all dental office personnel
- Receive emergency care or appropriate referrals in a timely manner
- Accept or refuse any treatment, drug, or procedure
Information and Communication
- Receive complete information about your diagnosis, treatment, and prognosis
- Access your dental records and receive copies upon written request
- Receive clear explanation of all costs, including treatment alternatives
- Have your privacy protected according to HIPAA regulations
Treatment Decisions
- Participate in decisions regarding your dental care
- Receive information necessary to give informed consent
- Seek second opinions when desired
- Change dentists at any time
Patient Responsibilities
Providing Information
- Provide accurate medical history and information about current conditions
- Inform the office of any changes in health status
- Provide current contact and insurance information
Compliance
- Follow the agreed-upon treatment plan
- Follow post-treatment care instructions
- Take prescribed medications as directed
- Attend scheduled appointments or provide 24-hour notice for cancellations
Financial Obligations
- Pay agreed-upon fees at time of service
- Provide accurate insurance information
- Accept responsibility for any charges not covered by insurance
Office Policies
- Arrive on time for appointments
- Supervise children in the office
- Turn off mobile devices during treatment
- Treat staff and other patients with respect
By signing below, you acknowledge that you have read, understand, and agree to these rights and responsibilities.
Signature: _________________ Date: _________________
Print Name: _________________