Sinclair Smiles
SINCLAIR SMILESOFFICE SCHEDULING POLICY To Our Valued Patients:The following information about our of?ce policies is provided for your understanding. We feel that the more you know about our policies and methods of practice, the more we can be of service to you and avoid possible misunderstandings and frustration.When making an appointment please realize we design our schedule to offer individualized quality care for you. We need 48 hours (2 working days) notice to change an appointment. This advance notice allows us to offer this valuable chair time to another patient who needs treatment. However, we do realize that circumstances sometimes prevent our patients from keeping their appointment. Regretfully, you may be billed a minimum of $50.00 per hour for the time lost if no advance notice is provided.I have read the above information.___________________________________ ________________ Signature DateTHE FACTS ABOUT FILLINGS (Dental Board of California Publication)I acknowledge I have read and been offered a copy of the Dental Materials Fact Sheet dated May 2004, from Sinclair Smiles as required by state law.___________________________________ ________________Signature Date ACKNOWLEDGEMENT OF RECEIPT FOR NOTICE OF PRIVACY PRACTICES *You May Refuse to Sign This Acknowledgement*I acknowledge I have read and been offered a copy of Sinclair Smile’s Notice of Privacy Practices.___________________________________Print name_____________________________________Signature_____________________________________DateFor Office Use OnlyWe attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:__ Individual refused to sign__ Communications barrier prohibited obtaining the acknowledgement__ An emergency prevented us from obtaining acknowledgement__ Other (Please Specify) _____________________________________________________________________________________ ................
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