Patient's Acknowledgment Form | Advanced Dental Care of Twin Falls

Patient's Acknowledgement Form

I acknowledge that I received and reviewed the office privacy policy for Advanced Dental Care of Twin Falls including all HIPAA regulations. I also do hereby authorize Advanced Dental Care of Twin Falls to release a copy of my dental records for insurance, referrals, or for any other dental need.

I understand the original dental record is property of Advanced Dental Care of Twin Falls. Any information obtained from the copy of the dental records requested by me is my responsibility and Advanced Dental Care is not liable for any use/misuse of this information.
Patient Signature (Enter Initials)*
Date*
Parent/Guardian Initials if minor
Missed Reservation/Cancellation Policy

It is our office policy that you call ahead to the front desk to reschedule a reservation within 24 hours of the reservation time, otherwise a $45 fee will be charged. This policy allows others that need these times to not be turned away from receiving care.

I acknowledge that I have read the above and understand that a fee of $45 will be charged to my account and due upon the next visit if no notice is given within the 24 hour window.
Patient Signature (Enter Initials)*
Date*
Parent/Guardian Initials if minor
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Patient’s Acknowledgment Form