Your Rights as a Patient
Access to Care
- Receive care regardless of race, gender, religion, or national origin
- Obtain emergency care when needed
- Request a second opinion
- Choose or change your endodontist
Information and Communication
- Receive complete information about your diagnosis and treatment options
- Access your medical records
- Receive explanations of all procedures and associated costs
- Ask questions and receive understandable answers
Privacy and Confidentiality
- Have your medical information kept confidential
- Private consultations and examinations
- Control who has access to your treatment information
Treatment Decisions
- Participate in treatment decisions
- Refuse treatment after understanding the consequences
- Receive information about alternatives to proposed treatments
Your Responsibilities as a Patient
Providing Information
- Provide accurate medical history
- Inform staff of changes in health status
- Report any medications, supplements, or allergies
- Disclose previous dental treatments
Following Treatment Plans
- Follow prescribed treatment plans
- Attend scheduled appointments
- Provide 24-hour notice for cancellations
- Complete recommended follow-up care
Financial Obligations
- Understand your insurance coverage
- Pay agreed-upon fees
- Discuss financial concerns promptly
- Meet payment arrangements
Office Policies
- Arrive on time for appointments
- Follow office safety and infection control protocols
- Treat staff and other patients with respect
- Refrain from disruptive behavior
Acknowledgment
I acknowledge that I have read and understand my rights and responsibilities as a patient at [Practice Name].
Patient Name: _________________
Date: _________________
Signature: _________________