Office Appointment Policy

Our dental team at Danville Pediatric Dentistry is committed to providing your child with excellent dental care. In return we expect you to attend every scheduled appointment on time.

• When you miss an appointment it may not cost you anything but there are costs to others.
• Make sure you keep every appointment. This appointment is for you.
• If you are not going to keep your dental appointment notify the office at least 24 hours ahead of time.
• If you do not notify the office 24 hours prior to the appointment and miss your appointment 2 times, you will no longer be able to come to this office for your dental care.

You and your child have the right to:

• Be treated with respect.
• Receive needed dental services.
• Privacy and confidentiality.
• Receive information about your oral health care and treatment options.
• Help make choices about your dental care.

You and your child have the responsibility to:

• Bring your current Medicaid or insurance card each time you come to an appointment.
• Tell your dentist when you have concerns about your oral health.
• Follow the advice and treatment plan of your dentist.
• Tell your dentist when the treatment plan is against your wishes.
• Keep all dental appointments.
• Show up on time for all dental appointments.

The dentist and dental team have the right to:

• Be treated with respect.
• Enforce all stated office policies regarding failed appointments, payment requirements, and acceptable behavior in the office.

The dentist and dental team have the responsibility to:

• Inform you of all needed treatment and tell you what could happen to your oral health if you do not have the treatment.
• Keep all appointments scheduled with you.
• Be on time for appointments scheduled with you, or tell you when they cannot be on time.

I have read and understand the information given to me in this agreement. I have had the chance to ask the dentist and dental team questions about the information.

I agree to show up for appointments that I schedule with Danville Pediatric Dentistry and to come to appointments on time.