Kids Stop Dental John L.

Barnett, DDS Pediatric Dentistry

Patient Partnership Agreement

Dear Responsible Party,

Please Read Carefully

We are delighted you chose our practice to provide your child's dental care needs. Our goal is to provide the highest level of Pediatric Dental care available to your c h i l d in the safest environment possible in a friendly and courteous manner. The Doctor/Patient relationship is a mutually beneficial! relationship and requires the commitment of both parties. In order for our practice to provide your child with the appropriate dental care, we need you commitment to our policies. Please read and initial each policy: 1. If you have private dental insurance, please provide the front office staff with your card so that your benefits can be obtained. Please keep in mind that dental insurance is a contract between you and the insurance company. As a courtesy, we will file insurance claims for you. We cannot guarantee coverage for any treatment. ALL co-payments, deductibles and fees for non covered services are to be paid at the time of service. ______ 2 We reserve specific appointment times in our schedule for your child's treatment It is your responsibility to remember your child's appointment and arrive on time In order for us to proper u t i l i z e the time we have scheduled for your child and out of respect for those patients who arrive on tune, late arrivals could result in vour child's appointment being rescheduled. If there is an emergency that prevents you from arriving on time, please notify our office as soon as possible so that we may adjust our schedule to accommodate you if possible______ 3 Broken appointments are not acceptable. Your appointment w i t h the doctor is a time set aside for vour child. If you need to change an appointment, we require a 24 hour notice Failure to provide us with a 24 hour notice will be considered a broken appointment. Failure to show for a scheduled appointment will result in a $25.00 broken appointment fee. Because of the hardship it places on our practice, repeated broken appointments will result in termination of our doctor/patient relationship. _______ 4. Following each examination, you will receive a treatment plan consisting of the necessary dental treatment for your child and and the estimated cost. The treatment recommendations are made according to acceptable standards of care and what I feel is in your child's best interest. You are encouraged to ask questions and be involved in the decision making when it comes to your child's treatment. Once we have agreed on a plan of treatment, we ask that you have the recommended treatment done in timely fashion to prevent more serious problems from occurring. Failure to follow through with treatment and preventive
care can result in vour child experiencing, more serious complicated dental problems _____

5 We encourage a parent to accompany their c h i l d during a l l appointments. However, Dr. Barnett must have your child's full attention at all times. Both he and child must be free from a l l distractions Therefore. Dr. Barnett asks that if parents want to remain with their child during any treatment, it is necessary that the parent is a "silent partner" during treatment. If being a "silent partner" is difficult. Dr. Barnett asks that you remain in the waiting room In the event Dr. Barnett feels the parents are needed during treatment, you will be invited to the treatment room. ______ 6 In order to keep your child's dental record current and accurate, we ask that you notify our front desk staff of any changes in address, phone numbers, insurance information and medical status as soon as possible ______ 7. By accepting treatment recommendations, you are entering into a contractual financial agreement to pay for services provided. We accept a variety of payment methods such as cash, personal check, money order, and credit/debit card. We require fees to be paid at the time of service unless prior arrangements have been made. If your account becomes delinquent due to unpaid balances, we reserve the right to seek remedy by any means available to us. If this procedure becomes necessary, you accept financial responsibility for any fees/charges encountered when attempting to collect on a delinquent account._____ We look forward to a long lasting, caring, and professional relationship with you and your child. If you have any questions or Concerns regarding the above office policies please feel free to address them. By signing below you accept our office policies.

Responsiable Party____________________________________________________________________________Date ________________________