Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESREFUSAL OF TREATMENT
Licensed dental professionals are held to a standard of care recommended by the American Dental Association and Wisconsin Dental Association. Failure to maintain standard of care may result in sanctions up to and including revocation of the license to practice. As a patient it is within your rights to refuse any recommendation made by the licensed dental professionals of this office, however, the licensed dental professionals of this office are required to maintain standard of care to continue practicing. If you refuse recommended treatments (i.e. x-rays, periocharting, frequency of "cleaning"), your ability to receive dental care at this office may be terminated.