1. A non-refundable deposit in the amount of 50% of the scheduled appointment will be required for all appointments before they can be scheduled. __________

2. The full amount of the deposit will be applied to your account the day of the appointment. __________

3. Failure to keep the appointment without 7 days notice will result in total loss of your deposit. A new deposit will then be required in order for us to schedule another appointment for your child. ____________

4. If you are unable to keep your child's appointment due to illness, a written note from your child's physician will be necessary in order to protect your deposit. __________

5. You must arrive at this office 15 minutes before the scheduled starting time. A late arrival may prevent us from being able to perform the scheduled work and would result in the loss of your deposit. _________

 

I have read and understand the above policy concerning keeping my child's dental appointment and the provisions of my non-refundable deposit with this office, and furthermore, agree to abide by the provisions set forth on this form.

Patient Name ____________________________________________

Signature _________________________________________________

Relationship to Patient _______________________________________

Date _____________________

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