Patient Responsibility Agreement

We ask that you partner with us in your dental care by following the School of Dentistry Oral Health Clinic rules and regulations affecting patient care and conduct as outlined below:

  1. Follow the agreed upon treatment plan recommended by the School and approved by you, the patient, in a timely manner.
  2. Make and meet appointments as outlined by your student doctors. If you cannot meet these times, please be courteous to your student doctor by giving at least 48 hours' notice for any cancellation.
  3. Provide accurate and truthful, current and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health and dental health.
  4. Make it known that you clearly understand a proposed course of treatment, and what is expected of you by giving your informed consent. Feel free to ask questions if you do not understand any directions or information given to you.
  5. Assure that the financial obligations for your dental care are fulfilled as promptly as possible. This includes making payment at the time of treatment, as well as providing accurate insurance information and asking questions you may have concerning your bill.
  6. Be considerate and respectful of the rights of other patients and of School personnel. We are committed to providing a safe, secure and respectful environment for all patients and staff. Words or actions that make others feel threatened or shamed will not be tolerated and may result in permanent dismissal from the School of Dentistry Oral Health Clinic.
  7. Remember you are responsible for the outcome if you refuse treatment or do not follow instructions.

Thank you for your consideration. We look forward to helping you with your oral health care needs.