Patient Forms


Find All The Patient Forms You May Need For Your Next Dental Procedure

Patient Forms
Please fill out these forms so we can expedite your first visit:

Patient Agreement

In order to enhance your experience as a patient, we would like to have a clear understanding of the expectations of initiating and continuing care here at O’Neill Family Dentistry. It is our expectation that you, the patient, will participate and accept recommended treatment with the understanding that not doing so releases the Dr. and Hygienist from responsibility of lack of care. That you will keep and be on time for all scheduled appointments, understanding that coming more than 15 minutes past your appointment time may mean you are rescheduled. The Dr. and Hygienist will be notified of any changes in health or medications. The patient will keep up to date with any balance and notify us of any insurance/benefits change. The patient will treat and speak to all members of the staff respectfully at all times. It is understood that breaking any part of the agreements may mean dismal as a patient.

Financial Agreement

Payment is due IN FULL at the time of the service. As a courtesy to our patients with insurance, we will file your primary insurance. The estimated portion of the uncovered fees are due in full at the time of your appointment. After all insurance payments are made any remaining balance is the patient’s responsibility, and will be billed to the patient. If for any reason payment is not made in 90 days a service charge of $25 will be added, and the family account will be sent to collections.

Confirmation Agreement

In order to be considerate of all of our patient's time and provide the quality dental care you desire we have set forth the following agreement. Thirty days prior to your dental appointment we will send you a reminder to the e-mail address on file. Two weeks prior to your appointment we will send you a confirmation text prompting you to confirm your upcoming appointment. All patients that have not confirmed will receive another confirmation text four days prior to your appointment. We will attempt to call all patients with unconfirmed appointments two days prior to your scheduled appointment. Your appointment is only considered confirmed when you communicate directly with our office via email, text or phone. If we have not received confirmation from you within 24 hours of the scheduled appointment, we reserve the right to release your appointment. 

Cancellation Agreement

We require a 24-hour notice in order to cancel or reschedule an appointment without your account reflecting a charge for the visit. We reserve the right to charge your account for any appointment that is cancelled, rescheduled, or missed without a 24-hour notice. There will be a charge of $25.00 for every hour scheduled. Payment will be due in full at the patient's next visit.