Island Dental
Center of Summerlin
Michael J. Tomita, D.D.S. & Stan S. Askew, D.D.S.
Island Dental Center
is pleased to provide high quality dental services at a reasonable
price, while paying careful attention to our patients' time
schedules. We hope that you can abide by the following guidelines to
help us accomplish our goals together.
*Time: We try to adhere to a strict time schedule so patients
are not kept waiting too long. We would appreciate having 48 hours
notice if you need to cancel or reschedule an appointment. We will
try to accommodate patients who show up late for their appointment,
but under no circumstances will we allow one patient's lateness
interfere with the following patient's appointment.
*Payment: One of the ways we try to limit paperwork (which
ultimately decreases patient costs) is by not sending out monthly
statements. We therefore must insist that payment is due in full on
the day of treatment. If your insurance has been pre-approved, only
your co-payment is due. Please do not ask us to bill you for
services already rendered. We accept Visa, Mastercard, Discover,
American Express, cash, and in-state personal checks (with proper
I.D.). You can also apply for a credit line, which can allow you to
make monthly payments for your treatment. Patients willing to pay
for extensive procedures in advance may receive a discount.
*Insurance: We gladly extend the service of pre-authorizing
and billing your insurance company for your dental services. We must
be able to verify insurance coverage either by copying your card or
by phone or computer. Please note-A pre-authorization from your
insurance company does not guarantee payment. If for any
reason your insurance company does not provide payment, your
account becomes immediately due in full. Also, being covered by 2 or
more insurance carriers does not guarantee that you will have no out
of pocket expense. Some secondary insurance carriers have refused
payment when they discover that the patient has received benefits
from another company.
*Divorced Parents: The adult accompanying the child to the
office is financially responsible for that visit. If the child is
covered by the ex-spouses insurance, we must have a copy of the
insurance card unless the adult accompanying the child wishes to pay
in full for the visit. We will not send statements to the ex-spouse
unless prior arrangements have been approved in writing.
*Children having treatment: We like to treat children
unaccompanied by parents. If you are uncomfortable with that, you
may join your child during treatment as long as there are no other
children with you. Newborns and infants are not allowed in the
operatories. Airborne bacteria and other germs created in back may
be unsafe for them to breathe. The staff will be happy to explain
all procedures to you either before or after the visit. Also, please
do not leave children unattended in the waiting room.
*Cell Phones: Please do not answer them during treatment. If
you can't resist, please turn them off.
*Your records: If you are moving, we will be happy to provide
a copy of your dental records to take with you. There is a $10 fee
for this service, and you must sign a legal release.
*We know someone as cool as you would never do something like
this, but...
There is a $20 charge
for all returned checks.
Patients who miss 3
appointments without notice within a 12-month period will not be
allowed to schedule future appointments with our office.
Accounts not paid for
90 days will be sent to an outside collection agency.
Anyone who exhibits
rude or abusive behavior will be asked to leave permanently.
If you understand
the above policies and agree to abide by them, please sign below:
Date:
MM/DD/YY
Patient Signature or Legal Guardian
NOTE:
Please print this form, fill out and either mail
it to our office, fax it to our office or bring it in
when you come in for your appointment.
Remember to fill out all 5 forms.
