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HIPAA Form

We want to thank you for choosing The Smile Shoppe as your dental care provider. In order to give you and all our patients, the best possible care, we request that you review our policy regarding missed appointments.

A missed appointment is when you fail to show up for an allotted appointment time, without a phone call or cancellation notice of at least 48 business hours. Please remember that we have reserved appointment times especially for you. Therefore, we request at least a 48 business hour notice in order to reschedule your appointment. This will enable us to offer your cancelled time to other patients.

**If you are unable to keep your scheduled appointment time, please call our office at least 48 business hours in advance in order to avoid dismissal. Your phone call is critical in helping us provide continuous care to all of our valued patients.

I have read and understand the policy stated above:

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Authorization of Recommended Services

Smile Shoppe Pediatric Dentistry is dedicated to providing your child with the highest quality of care. We follow the guidelines set forth by the American Academy of Pediatric Dentistry. With all of the changes that are occurring with insurance companies, our services may not always be covered. For example, it is recommended every 6 months to have a fluoride treatment to help lower the risk of childhood caries (decay). With that said there may be a charge up to $40 once per year to help protect your child from dental caries. **If you would not like fluoride placed please notify the assistant that is working with your child.

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2020 Acknowledgement of Receipt of Notice of Privacy Practices

I have received a copy of this office’s Notice of Privacy Practices. (Please notify the front desk if you would like a copy to take home) You may refuse to sign this acknowledgement; however, please note that refusal to sign would affect our ability to submit insurance claims on your behalf. This action would require payment in full at the time of service.

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