To:    Patients and/or Legal Guardians,

• Legal Guardians MUST bring Official Court Documents Showing Legal Guardianship of Minor Patients.
• All patients 17 years old and younger must be accompanied by a parent or legal guardian during entire dental procedures.
• You MUST fill out and sign ALL paperwork PRIOR to coming in for your appointment and bring all paperwork with you the day of your appointment!
• You MUST bring with you, a Valid Driver’s License or a Valid Picture ID and your Current Insurance Information!
• You MUST bring all Current X-rays from previous dentist OR all new x-rays will be taken the day of your appointment at the patient’s expense! Current X-rays Include:
       1.  Full Mouth X-rays (within 3 years)
       2.  Panoramic X-ray (within 3 years)
       3.  Bitewings (within 1 year)
• For Biohazard & Safety Reasons : Only 1 Adult may join a patient in treatment areas!  All Children MUST remain in Waiting Room with a RESPONSIBLE ADULT! (Our Staff is unable to watch children!)  Patients without a Responsible Adult to watch children in Waiting Room, will not be seen! No playing in the water fountain!
• No cameras, cell phones, texting devices or recording devices in treatment areas.
• If you are unable to keep your scheduled appointment, you MUST call and cancel at least 48 hours in advance to avoid a “Patient No Showed/Cancelled without Sufficient Notice” Fee for EACH patient that has a scheduled appointment! Exception:  If proof is provided of an emergency or extenuating circumstance!
• HIPAA Policy

Failure to complete the above may result in appointment rescheduling or denial of services!

Barth Family Dentistry is not responsible for lost, stolen or forgotten items.

Yours in Dental Health,
Barth Family Dentistry