Missed Appointment Policy

Missed Appointment Policy:

Please be advised that as per our office policy, and patient that misses 3 appointments without office without giving a prior 24 hour notice, will be discharged.

We apologize for any inconvenience. Everyone’s time is important and we value all our patients. Please be so kind and notify us if you have to cancel your appointment, so another patient may be seen at that time appointment time.

Office Policy for Payments:

All co-pays are always due at the time of service. Payment is due at the time of the procedure and must be paid in full.

Any major procedure will be pre-approved by your insurance company. There is no guarantee that your insurance will authorize a major procedure or make a payment towards it. In most cases, only a percentage is covered by the insurance company, therefore you are obligated to pay the other portion.

For coverage information and questions, please contact your insurance carrier.

Consent for Treatment:

I hereby authorize Dr. Kudla and staff to take x-rays, study models, and other diagnostic aids deemed appropriate by Dr. Kudla to make a thorough diagnosis of my dental needs.

Upon such diagnosis, I authorize Dr. Kudla to perform all recommended treatment mutually agreed upon.

Also, I understand that composite (white) fillings for posterior teeth are reimbursed as routine amalgam (silver) fillings and that I am responsible for the difference not covered by my insurance company.

I am also aware that crown prep procedures may require additional extensive treatment such as Root Canal Therapy which may not be covered by my insurance company, these additional charges I will be responsible for.

I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that I can ask for a complete recital of any possible complications.

I agree to be responsible for payment of all services rendered on my behalf of my dependents. I understand that payment is due at the time of services unless other arrangements have been made as stated in the financial policies description.

I am responsible for notifying the office prior to my scheduled appointment if I am unable to keep my appointment. I am also aware that if I do not, that I will be responsible for a $25.00 cancellation fee.

Authorizations and Release:

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I authorize Dr. Kudla to release my information including my diagnosis and the records of any treatment of examination rendered to my child (ren) or myself during the period of such dental care to third party payers and / or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependents as stated in the financial policies description.

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Signature of Patient or Parent / Guardian Date