Office Policies
Weiner Dental
Office Policies
Welcome to the office of Weiner Dental. Dr. Jeffrey M. Weiner and Dr. Jason D. Weiner pride themselves on providing quality dental care and do their very best to satisfy your dental needs. Our team of front desk receptionists, dental hygienists, and dental assistants are extremely friendly and skillful at their jobs. In order to provide our patients with the best care possible, we have certain office policies that we require our patients to follow. Some of these office policies include:
Health History: Please notify us of any changes in your health status BEFORE we begin treatment. This
includes any new medications, medical changes, allergies, or recent hospitalizations.
No Show Policy: Attendance is required at all appointments and cancellations with less than 48 hours
notice will incur at least a $30.00 missed appointment fee (depending upon the length of appointment and type of
treatment). Please respect the staff’s time and effort that goes into scheduling patients and call with enough notice.
Payment: All co-pays, deductibles, and fees are required to be paid at the time of the visit. We accept cash,
personal checks, debit cards, and major credit cards. We also accept CARE CREDIT (low or no interest financing).
Please ask our front desk team for more information.
Insurance Predeterminations: Our front desk team works extremely hard at gathering as much
information as possible. Please understand that predeterminations are only “estimates.” Your dental insurance company
will not provide 100% accurate fees until the work is completed and they receive your claim form from us. Please
understand that your dental insurance is specifically a contract between YOU and your INSURANCE COMPANY.
Insurance Downgrades: Please be advised that this office does NOT use amalgam silver restorations.
We use composite restorations which may or may not necessitate additional costs or co-pays. Certain insurance
companies “downgrade” on composite fillings, leaving greater expense to be paid by the patient. If you have dental
insurance, you may contact your insurance company for more information.
I am signing my name below to show that I have fully read the above policies and understand them completely.
Patient Signature: X________________________________ Date: __________
Agreement to Receive Electronic Communication
This form provides our practice with your agreement to receive communications via email, fax, and/or text. I agree that the dental practice may communicate with me electronically at the email address, fax number, and phone number listed below. I am responsible for providing the dental practice any updates to my email address, fax number, and phone number. I can withdraw my consent to electronic communications by calling 215-632-1612
Patient Name: ______________________________________________ Date of Birth: ________________________
Email Address:______________________________________________@__________________________________
Fax Number: ___________________________ Phone Number:___________________________________________
Patient Signature: X_________________________________________________Date:_______________
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