You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to
consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the
recommended procedure, alternative treatments, or the option of no treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your
dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness
to accept known risks and complications, no matter how slight the probability of occurrence.
It is very important that you provide your dentist with an accurate medical history before, during and after
treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication,
pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled follow up
appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Your
mouth truly is connected to your health. The patient is an important part of the treatment team. It is important to
report any problems or complications you are experiencing so they can be addressed by your dentist. It is equally
important to report your medical conditions to us. Certain heart conditions may create a risk of serious or fatal
complications. If you have a heart condition or heart murmur, high blood pressure, diabetes, pregnancy, or other
health conditions, advise your dentist immediately so she/he can consult with physician if necessary.
Please inform us of all medication you are currently taking on top of any medications that you are allergic to. If
you are taking oral birth control medication, you must consider the fact that antibiotics might make oral birth
control less effective. Please consult with your physician before relying on oral birth control medication if your
dentist prescribes or if you are taking antibiotics.
As with all procedures and surgery, there are commonly known risks and potential complications associated with
dental treatment. No one can guarantee you the success of the recommended treatment, or that you will not experience
a complication or less than optimal result. Even though many of these complications are rare, they can and do occur
occasionally. There are risk and limitations to all procedures. The practice of dentistry is not an exact science
and that, therefore, reputable practitioners cannot guarantee results. Complications resulting from the use of
dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections.
Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:
Pain, swelling, and discomfort after treatment;
Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation
by a dental specialist;
Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin,
gums and tongue along with possible loss of taste;
Damage to adjacent teeth, restorations or gums;
An altered bite in need of adjustment;
Possible deterioration of your condition which may result in tooth loss;
Allergic reaction to anesthetic or medication;
A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed
at a later point in time;
If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity
resulting in infection or the need for further treatment;
Infection in need of medication, follow-up procedures or other treatment;
The need for replacement of restorations, implants or other appliances in the future;
Need for follow-up care and treatment, including surgery;
Specific Problem Examinations
In the event that a patient requests only a specific problem be addressed (i.e. broken tooth, pain in one area,
etc.) this is considered a problem-focused evaluation. X-rays will be taken in this specific area only, and a
complete comprehensive examination will not be done. The dentist cannot diagnose problems in other areas of the
mouth. Any future treatment of other areas will require additional x-rays and a complete exam. You will not be
considered a patient of record unless this examination is completed.
Our office takes the minimum x-rays to allow us to do a thorough exam for each patient. Modern dental x-ray
equipment is extremely low dose radiation. Patient will receive a series of intra-oral x-rays. Diagnostic x-rays
provide the dentists with valuable information about your teeth and supporting bone that cannot be evaluated
otherwise. Without these x-rays, we cannot do a complete exam. We may also take photos of our patients as part of
their permanent record. We will not release these photos to anyone without your permission.
We must receive written consent prior to performing any non-emergency procedures on a minor. Grandparents,
step-parents, friends, relatives, etc. are not legally allowed to consent to dental procedures. Unless they have
been given written consent by the patient or legal guardian, please do not send your child to an appointment alone
or with someone else other than yourself unless you have filled out any necessary consent forms prior to the
appointment. Otherwise, we may have no choice but to reschedule your child’s appointment to another day.
I certify that I read and write English and fully understand this consent. PLEASE ASK THE DOCTOR IF YOU HAVE ANY
QUESTIONS CONCERNING THIS CONSENT FORM BEFORE SIGNING IT. By signing this form, I am freely giving my consent to
allow and authorize the doctor and/or his/her associates to render any treatment deemed necessary, desirable and/or
advisable to me, including the administration and/ or prescribing of any anesthetic and/ or medication.
Treatment Plan Estimates: Annapolis Dental Center prepares a Treatment Plan Estimate so that
patients can understand the estimated costs of their recommended treatment prior to its start. The Treatment Plan
Estimate is a good faith attempt to predict the cost of your treatment based on the facts known to Annapolis Dental
Center when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you
that different or additional treatment is necessary and your financial responsibility may change.
If you have dental insurance, it is important to understand that your actual insurance benefits may differ from the
benefits estimated in your Treatment Plan Estimate. Your Treatment Plan Estimate of insurance benefits is based on
information provided by your insurance company and by you. It is an estimate and your insurance benefits may be
higher or lower than estimated. In all cases, you are responsible for amounts not covered by your insurance, unless
prohibited by law or contractual agreement. In all cases, we encourage patients with insurance to refer to their
member handbooks or to call their plan administrators with any questions or concerns related to specific benefits.
Treatment Plans: All dental treatment plan presented to me is a breakdown of dental services that I
need to maintain a healthy mouth. All pricing presented to me for such services are guaranteed for thirty (30) days
Predetermination of Insurance Benefits: If you have insurance benefits, you may have the option to
seek a Predetermination of Benefits before you proceed with any treatment. Predetermination of Benefits is a process
whereby your insurance company or plan administrator tells you in advance of treatment what procedures may be
covered by your insurance plan, the amount the insurance company may pay toward those procedures and the amount you
may be required to pay. Requesting a Predetermination is like submitting a claim before the dental procedure or
service has taken place. Because the Predetermination comes directly from your insurer or plan administrator, the
risk of error as to your coverage is reduced. If your treatment includes extensive or complex services, such as
bridges, crowns, dentures or periodontal work, a Predetermination may be particularly helpful to allow you to
appropriately budget for the services or discuss any potential alternative treatment that may be available, if
The Predetermination of Benefits process give you useful information about what services may be covered. However,
your insurer will inform you that a Predetermination of Benefits in not a guarantee of coverage. A Predetermination
sets forth your expected benefits based on the information available to the insurer at the time the Predetermination
is prepared. The Predetermination may not consider, for example, a prior claim submitted by another dentist for
services provided to you, changes in your coverage that occur after the Predetermination is made but before the
services actually are provided, or the insurance company’s subsequent opinion that a condition could have been
treated by a less costly alternative to the service provided by your dentist.
The time it takes to receive a Predetermination from your insurance company or plan administrator can vary, from as
few as two weeks to as many as eight weeks. The decision to seek a Predetermination of Benefits or to proceed with
treatment immediately is your own, unless your plan requires otherwise. Please inform the Office Manager if you
would like to request a Predetermination of Benefits from your insurer.
Insurance Estimate: For your convenience, we are happy to submit your dental claims and accept
payment from your insurance company. Your insurance contract exists solely between you and your insurance carrier.
We cannot be responsible for the limitations and exclusion determined by your participating insurance plan. With
that being said, the insurance portion of the treatment plan is only an estimate and does NOT guarantee that your
insurance carrier will pay their estimated portion. Your estimated portion will be due at the time of service. If
your insurance carrier downgrades your services or pays a lesser amount according to your coverage then you, the
patient will be responsible for the remaining balance due within thirty (30) days of receiving your Explanation of
Benefits from your insurance provider. I authorize and request my insurance company pay directly to Annapolis Dental
Center. I agree to be responsible for payment in full for all services not paid by insurance company for myself and/
Payments Accepted: Cash, Flex Spending, Credit Cards, and Care Credit. All children must be
accompanied by a parent during services.
Complications: The risk of complications from medications used/prescribed with general dental
treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nausea, allergic
reactions, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It is not
advisable to operate any motor vehicle or hazardous device while experiencing side effects of the medications we may
Anesthetic: The use of local anesthetic is used for pain control during dental procedures. There
are inherent risks and side effects. They include, but are not limited to: swelling, bruising, soreness, elevated
blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete
numbness may linger after the dental appointment. In rare cases, it can last for an extended time and potentially it
can be permanent.
Medication: Any medications dispersed or prescribed are the patient’s responsibility to understand
before taking. Particular attention should be given to possible allergic reactions, drug interactions with current
medications and their specific side effects.
Guarantees: I accept and agree that there are risk and limitations to all procedures. I understand
that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results.
I acknowledge that no guarantee or assurance has been made by anyone regarding dental treatment that I have
requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been
answered to my satisfaction. I consent to allow Annapolis Dental Center to take x-rays and perform an examination on
Notifications: It is the patient’s responsibility to notify the dentist and/or staff of Annapolis
Dental Center within thirty (30) days of service if there is a problem. Through this notification, we will be able
to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another
health care practitioner may be warranted. Any concerns past thirty (30) days will be the responsibility of the
patient and any services provided will be an additional cost to the patient.
Appointment Cancellation: When an appointment is made, we set aside an allotted time for your
procedure. In the event you are unable to give us 24 hour notice, there will be a $50.00 per person cancellation fee
charged to your account from Mon. - Thurs. appointments and $75.00 per patient cancellation fee for Friday and
Delinquent Accounts: There is a $25.00 charge to your account for any returned check fee. We will
submit all checks twice (2x) into your bank for payment. There is an interest of 5.25% per annum that will be
charged on any unpaid balance over sixty (60) days. Any accounts over ninety (90) days delinquent will be sent to a
collection agency and a collection fee of 35% of the balance will be charged to your account.
Refund Policy: You may discontinue treatment and request a refund from Annapolis Dental Center at
any time. Annapolis Dental Center will refund any amount paid for treatment that you did not receive, except when
Annapolis Dental Center’s policy for Interrupted Services. Patients requiring crown or bridge services may cancel
treatment with no charge prior to natural teeth being prepared or altered for the prosthetic. Once tooth preparation
occurs, patients are liable for the estimated full cost of the services even if they choose not to complete
Cash or Check Payment Refunds: Account Holder Refund Request - Upon receipt of a request for a
refund, Annapolis Dental Center will confirm all payments by check have cleared the bank (may take up to 15 business
days). Once the credit balance is confirmed, Annapolis Dental Center will issue a refund check within ten (10)
business days. All refunds will be processed back to the original form of payment, except cash payments will be
refunded by check.
I CERTIFY THAT I HAVE READ AND I UNDERSTAND THE ABOVE INFORMATION. I acknowledge that all my questions have been
answered to my satisfaction. You have the right to accept or deny treatment before it is performed. The fee(s) for
these services have been explained to me and I accept them as satisfactory. I understand the insurance estimate is
not a guarantee of payment and that I am responsible for any difference in payment. By signing this form, I am
freely giving my consent to authorize Dr. Dele including the administration and/or prescribing of any anesthetic
agents and/or medications. Annapolis Dental Center reserves the right to change or cancel these terms and conditions
at any time.