ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Book An Appointment

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Patient Name*
Address*
Patient Status*
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Consent*
Date of Acknowledgement*
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Appointment Cancellation Policy

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We strive to provide the highest level of dental care to each of our patients. When an appointment is scheduled for you, we set aside a certain amount of time for our team to complete your dental treatment.

We will make every effort to confirm your appointment with texts, emails and phone calls. When you receive these messages, please respond and confirm your appointment time. If you must cancel your appointment, we ask that you notify us at least 24 hours in advance of your scheduled appointment time. This will enable another patient who is waiting for an appointment to be scheduled in that time slot.

If you miss your appointment or if you cancel with less than 24 hour notice you will be charged a $25 for an appointment with the hygienist and $50 for an appointment with the doctor. The fee may be higher depending on the amount of time set aside for your appointment. This fee cannot be billed to your insurance company and it must be paid prior to your next appointment. No future appointments can be scheduled, and no records may be transferred until this fee has been paid.

Additionally, if a patient is more than 10 minutes late for an appointment without prior notice, we will consider this a missed appointment and the $25 cancellation fee will be charged.

We understand that emergencies and unforeseen circumstances occur, but we do expect the courtesy of a phone call. We firmly believe that good doctor/patient relationship is based upon mutual respect and communication. We value our patients and appreciate your understanding.

I have read and understand the Appointment Cancellation Policy of the practice and agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to- time by the practice.

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PATIENT RECORD TRANSFER REQUEST

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MM slash DD slash YYYY
Date*

Please forward current bitewings, fmx or pan that you may have to our office at the below address or, if digital, email to Info@ChrisSiachosDMD.com. We appreciate your prompt attention to this request!

Chris N. Siachos, DMD 1352 Cleveland Street Greenville, SC 29607 Ph: 864-271-9582 Fax: 864-509-0157
Please list the name(s) if you are requesting x-rays for family member(s) under the age of 18. Include name and date of birth.
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