New Patient Information

SMILE HIGH DENTAL CARE

10311 WASHINGTON STREET
THORNTON, COLORADO 80229

SPECIAL NOTE TO NEW PATIENTS

A PROFESSIONAL CLEANING PERFORMED BY A DENTAL HYGIENIST OR A DENTIST IS A MEDICAL PROCEDURE AND MUST BE PRESCRIBED BY A QUALIFIED HEATH CARE PRACTITIONER. IN SOME CASES, DENTAL CONDITIONS EXIST THAT HAVE TO BE ADDRESSED BEFORE A CLEANING IS POSSIBLE. IN THESE CIRCUMSTANCES, OTHER TYPES OF TREATMENT MAY BE REQUIRED FIRST, IN ORDER TO BEST PROVIDE FOR THE HEALTH OF THE PATIENT.

BECAUSE OF THIS, LEGALLY AND ETHICALLY, AN EXAMINATION AND X-RAYS – AS REQUIRED BY THE DENTIST – MUST BE DONE BEFORE A CLEANING CAN BE GIVEN. AFTER AN EXAM AND X-RAYS HAVE BEEN DONE, THE DOCTOR WILL BE ABLE TO SEE WHETHER OR NOT A CLEANING IS NEEDED AS THE NEXT STEP, OR IF A DIFFERENT PROCEDURE IS REQUIRED FIRST.

DR. JENNIFER HELGESON AND HER STAFF ARE COMMITTED TO HELPING THEIR PATIENTS ACHIEVE AND MAINTAIN HEALTHY TEETH AND GUMS FOR THE LONG TERM. THE PROCEDURES WE FOLLOW ARE IN THE INTEREST OF ACHIEVING THIS FOR AS MANY OF OUR PATIENTS AS IS POSSIBLE.

I have read the above statement and have been given the opportunity to ask any questions about it.
I understand it.

IN THE EVENT THAT YOU DECIDE TO SEEK DENTAL CARE FROM A PRACTICE OTHER THAN SMILE HIGH DENTAL CARE AND/OR DR. JENNIFER HELGESON – PLEASE BE ADVISED THAT A $50 RECORDS PREPARATION FEE WILL NEED TO BE PAID BY YOU PRIOR TO US RELEASING YOUR RECORDS/X-RAYS TO ANOTHER PRACTICE

SMILE HIGH DENTAL CARE

10311 WASHINGTON STREET
THORNTON, COLORADO 80229

FINANCIAL POLICY

Cash patients are expected to pay with cash, check or credit card the day the service is scheduled - unless specific arrangements are made in advance.

For those patients covered by insurance, we will accept assignment of benefits. This means you must sign the portion of your insurance form that assigns payment to our office.

Most policies do not cover 100% of the cost of your treatment. Because of this, and the extreme delay in receiving payment from the insurance company, you will be asked to pay the deductible, if any, and your portion of the charges the day the service is scheduled.

We will estimate, as closely as possible, your coverage, but until we actually receive the payment from the insurance company, it is just an estimate. We will assist you in dealing with the insurance company, but ultimately the responsibility lies with you. If, after 45 days, the insurance company hasn’t paid, the balance will be due, in full, by you.

If you have any questions, feel free to ask them at any time. We wish to be of assistance in any way we can.

SMILE HIGH DENTAL CARE

10311 WASHINGTON STREET
THORNTON, COLORADO 80229

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

*YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT*

I have received a copy of this office’s Privacy Practices: