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2. Welcome!

   Our goal is to provide you with the best service possible. These are our clinic policies. Please review them carefully.

4. Please check in 15 minutes early.

   Please check in at the front desk 15 minutes before your appointment.  If you are late for your appointment, we might not be able to see you or your child that day.

6. Children under 18 must have a parent or legal guardian with them.
   • A parent or legal guardian must come to every visit and stay in the Dental Clinic waiting area during the appointment. This is important in case of an emergency or if we need to talk with you about treatment.
   • We cannot provide dental care to your child unless a parent, legal guardian, or an adult with a notarized permission form brings them.
   • Children under 18 cannot be left alone in the waiting room. A parent or responsible adult must stay with them at all times.
8. If you are unable to keep your appointment, please call to cancel appointments at least 24 hours in advance.
   • Call or leave a message at (919) 245-2435.
   • If you do not contact us to cancel your appointment, it is called a broken appointment.
   • If you have three (3) broken appointments in one year, we will add your name to our Broken Appointment List.
   • If your name is on this list, we cannot schedule appointments for you in advance. You can still call us to see if we have a same-day appointment available.
10. All patients must show current proof that they live in Orange County.

    If you want to receive a sliding fee discount, you must show this proof at your first visit and once every year. Examples of acceptable proof include a driver’s license, utility bill, or lease agreement.

    Patients without dental insurance

    • You must provide proof of income for everyone in your household who earns money. This is required at your first visit and each year after that.

    • You will be charged a minimum fee of $40.00 at every visit.

    • Other charges will depend on the sliding fee scale and the treatment you receive.

    • We may not schedule return appointments until any unpaid balance is paid.

    Patients with Medicaid, NC Health Choice for Children, or Private Dental Insurance

    • Bring your insurance card to every visit.

    • At check-in, be ready to pay any copays required by your Medicaid or NC Health Choice plan.

    • If you have private dental insurance, you will be billed for any costs your insurance does not cover.

    • If you do not bring the required insurance information, you will be charged as a self-pay patient and will need to pay for your treatment at the time of your visit.

      
      
12. As a patient, or a parent/guardian of a patient, I agree to tell the Health Department if my income, address, or phone number changes.
14. Patient/Parent/Guardian Initials

    We will get your signature during your appointment.

15. Date
    Date
17. Orange County Health Department Staff Signature
18. Date
    Date
20. Interpreter initials

    We will get a signature during the visit. 

21. Date
    Date
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23. 1. Receive an email copy of this form.
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