Patient Forms

Patient Consent & Authorization Form

I have had the treatment plan(s) for my child explained to me.

The risks involved with those procedures, alternatives to those procedures, risk therein involved, and the risks of no treatment have also been explained to me and I understand the explanations. I have been given an opportunity to ask questions and have those questions answered.

Based on these explanations, I have agreed that my child is to be treated at LAVU DENTAL, according to the treatment plan and:

a. Authorize the administration of local anesthetic deemed necessary for the performance of dental procedures.

b. Authorize the taking of any records, x-rays, or photographs as is deemed necessary in the treatment and the use of such records, x-rays, or photographs by LAVU Dental, its doctors, staff, or any other entity authorized by Lavu Dental.

c. Acknowledge that all original records and diagnostic aids are the property of by Lavu Dental. Copies may be furnished upon written request based on established policies of the office. There may be a fee for duplication and/or transfer of records.

d. Grant permission to Lavu Dental, its doctors, staff, or any other entity authorized by Lavu Dental to reproduce, or use at its sole discretion, any records, x-ray, data, images, or photographs in any form or by any means for the purpose of illustration or publication on, but not limited to, our website, in professional journals, or any other type of media. I understand that any and all of such media will be copyrighted property of LavuDental, its doctors, staff, or other entity authorized by Lavu Dental. Whenever possible, data, records, and diagnostic aids used for purposes other than normal outpatient clinical operation will not contain identifying information.

e. I authorize the transmission, electronic or other means, of data for payment or communication purposes including but not limited to insurance companies. I acknowledge I have received and/or reviewed a copy of the Dental Materials Fact Sheet and Patient Privacy Notice.

f. Acknowledge that appointments are scheduled in advance. It is essential, therefore, that all appointments be kept promptly. In the event that an appointment cannot be kept, I will notify Lavu Dental at least 2 business days in advance, so that my appointment can be rescheduled or a missed appointment fee may be charged.

Lavu Dental reserves the right to discontinue treatment if, in its sole opinion, circumstances justify such action. Among reasons for discontinuation of treatment are repeated lateness and failure to keep appointments. I will provide the same courtesy to the office staff and other patients which I expect in return.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and consent to the submission of my electronic signature.*

Financial Policy

Our main concern is that you receive the proper and optimal treatments needed to help restore wellness. If you have any questions or concerns about our payment policies, please do not hesitate to ask our office manager.

Payment in full is due at the time that service has begun. We accept cash, checks, Visa, MasterCard, and Discover. We also participate with and accept CareCredits. We provide billing of insurance claims as a free service. In the case of insurance coverage which is payable directly to us, we will provide you with our best estimate of the amount that is due as your portion and that amount is due at the beginning of that procedure.

1. Your insurance policy is a contract between you, your employer and the insurance company. We are not a party to that contract. Our relationship is with you and not your insurance company. Questions outside of pre-estimates will be dealt with by you calling your insurance.

2. All charges are your responsibility. Whether your insurance company pays or not you are the responsible party. Many insurance companies arbitrarily select services they will not cover. We also offer to send a pre-treatment estimate for your work after you have completed your initial visit. Once you have received this from your insurance it may be used as a guide for you to use as the amount due at each visit.

3. If for any reason your insurance company does not pay for your services within 30 days, we will require you to pay the full amount due.

4. Returned checks and balances older than 30 days may be subject to additional collection fees and monthly interest charges of 1 1/2 %

Please note that cancellations require a 24-hour notice. Cancellations made in less than than 24 hours may result in a charge. Multiple cancellations will result in being dismissed as a patient.

Thank you for your confidence in our services by choosing us as your dental care provider. We appreciate your trust and the opportunity to serve you.

Confirmation

I understand that checking this box constitutes a legal signature confirming that I acknowledge and consent to the submission of my electronic signature. *

Please be aware Dr. Sushma Lavu does not participate in any plan with assigned benefits other than DELTA DENTAL.

All other insurance plans are willing to work with the dental office and in most cases will send us partial reimbursement directly. The result of this patients must pay in full at the time of service and will be reimbursed once we receive the payment from your insurance plan. Please call you insurance company if you need details on this.

Your initial visit for record taking and exam may be as much as $260.00.

This appointment will be two hours.

Thank you for your confidence in our services by choosing us as your dental care provider.

We appreciate your trust and the opportunity to serve you.