We firmly believe that successfully helping our patients achieve their treatment goals is first and foremost dependent upon creating the proper environment. We strive to provide each and every one of our patients with the individual attention that we feel people deserve and desire. We schedule enough time to listen, thoroughly examine, educate, and assist with treatment decisions prior to commencing treatment. You're appointment time is exclusively yours and you will have the doctor's undivided attention. We feel that thoroughness in communication is just as vital as thorough examination and treatment and results in improved patient satisfaction. Education related to treatment options is a top priority in our practice because we believe it allows you to choose the treatment that best suits your needs. The treatments recommended are based solely on diagnosis and patient desires and not on what insurance companies will or will not contribute towards. By doing this we ensure that we are looking out for your interests and are not influenced by insurance company policies which are designed to have their financial interest at heart.

Simply stated we: Listen, Evaluate, Educate, and Treat

PLEASE FAMILIARIZE YOURSELF WITH OUR TMJ & OFFICE POLICIES:

We require payment in full upon completion of all TMJ related appointments regardless of insurance status, or type of treatment provided. Most TMJ procedures are considered medical, but there are some procedures that may be considered dental. If you have medical and/or dental insurance, please bring your insurance cards with you to your appointment so we may verify coverage and obtain coverage benefits. If your treatment will be filed with major medical insurance please be aware that we are not a participating provider for any medical insurance company and are therefore considered out of network. Once you complete your case presentation appointment you will be given a completed medical insurance claim form and other standard information required by the insurance carrier so you can file the claim and get reimbursed. Please be aware that your out of network deductible will need to be met (if it hasn't been met already) before your insurance company will begin to reimburse you.             

  • We require a deposit of $100.00 in order to reserve your initial appointment.
  • If you need to cancel the initial appointment, your deposit will be refunded if it is greater than 7 days from the appointment.
  • If you need to cancel or reschedule your initial appointment and it is less than 2 days from your appointment you will forfeit your entire deposit and will need to place a new $100.00 deposit if you would like to reserve a new initial appointment.
  • Regular appointments canceled less than 48 hours and no shows for appointments are subject to a penalty fee of $50.00 per hour of appointment time.
  • Please be aware that cancellation of a Monday appointment must occur by 4 pm the Thursday prior in order to avoid an inadequate cancellation fee.
  • Late arrivals to appointments may be rescheduled and subject to a fee.
  • Excessive inadequate cancellation and no shows will require a deposit to secure future appointments.
  • Emergency TMJ treatment (patients acutely locked closed or locked opened, and not a patient of record of our practice) are required to place a 50% deposit of the estimated appointment total in order to reserve an appointment.

We truly value our relationships with our patients. Like any relationship, communication is vital to avoid misunderstandings and hard feelings. This document is the first step in developing an open and honest relationship. If there is ever anything that you don’t understand whether related to your treatment or your account with us, please don’t hesitate to ask questions. We will do our very best to help clarify things for you. Again, thank you for choosing our practice. We look forward to working with you to achieve improved oral and cranio-mandibular health.

Sincerely,

Dr. Steven Gold and Staff

Please arrive thirty minutes early to this appointment and remember to bring your medical and dental insurance cards as well as the following completed forms with you: this form, medical history, TMJ patient questionnaire, and HIPPA form. Please allow plenty of time to thoroughly and accurately fill out the TMJ patient questionnaire prior to your first appointment. We recommend starting this form several days prior since you may need to search for information from years ago.

  -WE WILL ASK YOU TO SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND OUR POLICIES.

I __________________________ have read the above information and policies of the office of New Garden TMJ & Dentistry. I have had the opportunity to ask questions, received satisfactory answers to my questions, and fully understand and intend to abide by the above policies.

 

PATIENT SIGNATURE: __________________________________ DATE: _________

 

PARENT/LEGAL GUARDIAN SIGNATURE: _________________________________