Dental History (Please indicate, if applicable)
Medical History (Yes or No if you currently or have had any of the following conditions in the past.)
It is very important to us that we take care of your speciﬁc needs.
Please check either YES or NO to the things that pertain to you.
Consent for Treatment
I hereby certify that all above patient, medical, and dental information is correct and authorize Dr. Fryer and staﬀ to take x-rays, study models, photographs, or any other diagnostic aids seemed appropriate by Dr. Fryer to make a thorough diagnosis of my dental needs.
I authorize Dr. Fryer to perform any and all kinds of treatment, medication, and therapy that may be indicated. If any conditions are discovered in the course of treatment which, in the opinion of the doctor require additional procedures or procedures diﬀerent than those described, I also authorize the performance of these procedures.
I also understand that the use of anesthetic agents embodies a certain risk.
I understand that my dental insurance is a contract between me and the insurance carrier and NOT between the Doctor and that I am still fully responsible for all dental needs.
These fees are due and payable at the time services are rendered unless prior ﬁnancial arrangements have been made. I also assign all insurance payments to the Doctor.
Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred.
I hereby state that I have read and understand this consent, and that all questions about the procedures have been answered to my satisfaction.
I consent for Kevin W. Fryer DDS Inc to send dental claims on my behalf (if applicable) and that the claim payment be sent to this oﬃce.
Warranty/Missed Reservation Policy
At Kevin W. Fryer DDS Inc., we pride ourselves on providing optimal dental health to all of our patients and their families. We stand behind our work, which is why we are happy to provide to you a 5 year warranty on a variety of services, something few other oﬃces oﬀer.
If our sealants, composite ﬁllings, veneers, inlays, onlays, bridges, or crowns need replacement within 5 years, and the tooth is still restorable, we will replace the restoration of the same type, at no cost to you! All that we ask is you do your part in maintaining optimal dental health.
If you brush and ﬂoss in the morning and in the evening daily, come to our oﬃce for your regular 6-month check-up, and complete all the recommended treatment at our oﬃce, you can prevent most or all disease. You must been seen at least twice a year (at our oﬃce) for a check-up to consider our warranty in eﬀect.
Missed Dental Reservation Policy
At Kevin W. Fryer DDS Inc, we pride ourselves on being prepared and ready for our patients. We kindly ask the same from you! If you ever need to reschedule a dental reservation with our oﬃce, there are many ways to reach our oﬃce-you can call us at 440-585-4200, email us at firstname.lastname@example.org, text us at 440-646-1004, or stop in.
If you are unable to make an appointment, we ask for a 48 hour notice to avoid a $50 fee.
Authorization and Consent to Use and Disclose Medical Information
The Medical Privacy Notice of Kevin W. Fryer DDS Inc provides information about how we may use and disclose conﬁdential medical information about you. You have the right to read our Notice before signing this consent. The terms of our Notice may change from time to time. If changed, we would inform you at your next visit.
By signing this Authorization, you agree to let us use and disclose conﬁdential medical information about you for treatment, payment, and dental oﬃce operations. This includes information about your dental health and medical health. You are also consenting to the release of health information about you to your insurer, third party, or other agents needed to get payment for your treatment.
Signature of Patient/Guardian
I have read the above warranty.
I have read the above policy.
I have read the above policy.