We are committed to support you in understanding your dental health, so that you will always be able to make the best choices.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary, and I consent to the release of this information.

I authorize release to my insuring company plan administrator, the information contained in claims submitted electronically and when applicable hereby assign my benefits to Drs. James Chacko, Hamsaveni James and/or associates and authorize payment directly to Crystal Dental. Further, I agree that I am fully responsible for the total payment of all procedures performed in this office. This includes any treatment that is not a benefit of any dental insurance that I may have.

MISSED APPOINTMENTS

Appointment Times are reserved especially for you. Please be on time so that the scheduled treatment can take place.

If for any reason you should need to change your appointment, there will be no charge, provided you give us 2 full business days notice. If an appointment is cancelled with less than 48 hours notice, a potential fee of $50 may be applied to your account.

Please help us serve you better by keeping your scheduled appointments. We are here to assist you in any way possible. If you have any questions or concerns, please advise our team.

Our goal is to ensure that you have an outstanding experience here at Crystal Dental!