OFFICE POLICY AGREEMENT

CONSENT FORM, If applicable:

Consent to receive dental treatment: I hereby consent and authorize the doctors and staff members to examine, clean and provide dental treatment to my child. I further consent and authorize the taking of dental x-rays, as they may be considered necessary to diagnose and/or treat my child.
Minor Drop-Off Consent: In the event I drop off my minor child to receive dental services, I hereby consent the doctors and staff, to clean and provide dental treatment to my child. I have listed a contact person to be reached in case of emergency below:

FINANCIAL POLICY

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I acknowledge that all financially responsible parties are to be present for all treatment planning and financial estimates. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance. In the event my account balance remains unpaid in excess of 90 days, I understand that my account will be turned over to a collections agency. I accept full responsibility for all administrative costs and legal fees associated with the collections process. I agree to
reimburse the fees of any collection agency, which may be based on a percentage at a maximum of 54% of the debt, and all costs and expenses, including reasonable attorney’s fees that the dental office incurs in such collection efforts.

I understand that there is a broken appointment policy and I may be charged $40, unless I notify the office within 2 business days of my cancellation.

For your convenience our office takes personal checks. However, I understand a $50 fee will be applied to my account for a bounced check (NSF) and from that point forward, personal checks will no longer be acceptable form of payment.

ASSIGNMENT AND RELEASE

I, the undersigned, have insurance with and I authorize my insurance company to assign benefits directly to my dental provider, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance within 30 days from the date of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

WAIVER OF JURY TRIAL

By signing below, I hereto irrevocably waive any and all right to trial by jury in any legal proceeding arising out of or related to this agreement or any treatment services provided by offices affiliated with Narducci Dental Group, P.A., its associates, shareholders, and employees. The scope of this waiver is intended to be all-encompassing of any and all disputes that may be filed in any court and that relate to the subject matter of this agreement.

By signing below, I accept the above terms set forth by the dental office and acknowledge full understanding of said terms.

INFORMED CONSENT FORM FOR GENERAL DENTAL PROCEDURES

You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instruction, referrals to other dentists or specialist, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition, advise your dentist immediately so your physician can be consulted if necessary.

If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.

As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to the following:

1. Pain, swelling, and discomfort after treatment.

2. Infection in need of medication, follow-up procedure or other treatment.

3. Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste.

4. Damage to adjacent teeth, restorations, or gums.

5. Possible deterioration of your condition which may result in tooth loss.

6. The need for replacement of restoration, implants or other appliances in the future.

7. An altered bite in need of adjustment.

8. Possible injury to the jaw and related structures requiring follow up care and treatment, or consultation by a dental specialist.

9. Root tip, bone fragment or a piece of dental instrument may be left in your body, and may have to be to be removed at a later time if symptoms developed.

10. Jaw fracture.

11. If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for future treatment.

12. Allergic reaction to anesthetic or medication.

13. Need for follow up treatment, including surgery.

This form is intended to provide you with an overview of potential risks and complications. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

COVID -19 CONSENT

COVID CONSENT FORM, If applicable:

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , hereby acknowledge that I have received and reviewed a copy of Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of Privacy Practices.

I understand that Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of
Privacy Practices may change periodically and that I am entitled to receive a copy of Narducci
Dental Group, P.A., and affiliated dental practices revised HIPAA Notice of Privacy Practices
upon request.

I understand that, if I have questions about Narducci Dental Group, P.A., and affiliated dental
practices HIPAA Notice of Privacy Practices, I may contact Narducci Dental Group, P.A., at (904)
998-7000.

I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and
that Narducci Dental Group, P.A. and affiliated dental practices will not refuse treatment to me if I
refuse to sign this Acknowledgement.

I further understand that I may contact the Secretary of the U.S. Department of Health and
Human Services should I have concerns regarding Narducci Dental Group, P.A. and affiliated
dental practices privacy policies and procedures. For information on how to contact the U.S.
Department of Health and Human Services, please ask Narducci Dental Group, P.A., at (904)
998-7000, noted above, for assistance.

DISCLOSURE

BISPHOSPHONATE THERAPY AND CONSENT TO CONSERVATIVE SURGICAL AND NON-SURGICAL THERAPY

Bisphosphonates are a type of drug given to millions of Americans to treat osteoporosis or as part of cancer treatment, namely for breast cancer, lung cancer, prostate cancer, multiple myloma, Paget’s disease of the bone, alveolar necrosis of the bone or post￾menopausal osteoporosis. They are sometimes given orally and other times are given through people’s veins. Some of the common names include but are not limited to:

1. Actonel (Risedronate)

2. Bonefos (Clodronate)

3. Fosamax (Alendronate)

4. Fosamaz Plus D (Alendronate)

5. Aredia (Pamidronate)

6. Didronel (Etidronate)

7. Boniva (Ibandronate)

8. Ostac

9. Skelid (Tiludronate)

10. Zometa (Zolendronic Acid)

11. Pamidronate

In rare instances, some people on these drugs have developed a condition called Osteonecrosis of the jaw, which results in severe damage to or loss of the jaw bone. Symptoms include but are not limited to pain, swelling or infection of the gums or jaw, gums that are not healing, loose teeth, numbness or a heavy feeling in the jaw, drainage and exposed bone. There is no proven treatment to fix this problem.

Accordingly, patients on these drugs should know the risks, benefits, and alternatives of invasive dental procedures. If a patient is on Bisphosphonates, your dentists, follows special procedures to promote the safety of the patient. It is very important that you let the dentist know whether you are taking any medications, particularly a Bisphosphonates drug, or if you have ever taken a Bisphosphonate drug. If you are not sure if the drugs you are taking are Bisphosphonates, ask the dentist. You have a duty and responsibility to tell the dentist all the drugs that you take.

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I hereby disclose that:

YES, I AM on a Bisphosphonate or have taken one in the past. It is called: I have taken this medication for: (Amount of time) NO, I am NOT on any Bisphosphonates and have never taken or been given Bisphosphonates.

IF YOU CHECKED “YES” ABOVE, COMPLETE THE FOLLOWING:

I UNDERSTAND THAT THE COMPLICATION STATED ABOVE CAN HAPPEN WITH SURGICAL AND NON-SURGICAL
TREATMENT, AS WELL AS, SPONTANEOUSLY AND AGREE TO PROCEED WITH THE RECOMMENDED TREATMENT:

Consent To receive text message and electronic communication alerts

We have the ability to send text and email messages to your provided cell phone number to receive account information such as appointment reminders, appointment openings, account updates, marketing specials, opportunities, and other alerts

Please indicate below whether you would like to receive text and email confirmation,reminders,newsletters,specials, and other updates. Text message charges from your cell phone provider may apply.

By signing below, I wish to enroll in the text message and email alert communication explained above

You can withdraw your consent at any time by calling the office. You are resposible providing updates to your cell phone and email information

It is important to note that text communication is not always secure. Text messages can be intercepted and for this reason, we do not communicate personal health information through this method.