Your Rights as a Patient
Access to Care
- Receive treatment without discrimination based on race, gender, age, religion, ethnicity, or disability
- Obtain emergency dental services when needed
- Receive complete information about your oral health status
Information and Communication
- Receive clear explanations about diagnosis, treatment options, and prognosis
- Access your dental records upon request
- Be informed about the costs of treatment before services are provided
- Receive answers to questions about your periodontal care
Privacy and Confidentiality
- Have your medical and dental information kept confidential
- Privacy during examinations and procedures
- Review and receive copies of your dental records
Treatment Decisions
- Participate in decisions about your treatment
- Refuse treatment after understanding the consequences
- Receive information about alternatives to proposed treatments
Your Responsibilities as a Patient
Providing Information
- Supply accurate and complete medical history
- Inform us about changes in your health status
- Provide updates about medications you are taking
Following Treatment Plans
- Follow the agreed-upon treatment plan
- Practice proper oral hygiene as instructed
- Attend scheduled appointments
- Complete recommended follow-up care
Financial Obligations
- Provide accurate insurance information
- Pay agreed-upon fees in a timely manner
- Understand your insurance coverage
Office Policies
- Arrive on time for appointments
- Provide 24-hour notice for cancellations
- Follow office safety and infection control protocols
Acknowledgment
I have read and understand my rights and responsibilities as a periodontal patient.
Patient Name: _________________
Signature: ____________________
Date: ________________________