ABOUT YOU

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry our treatment, payments activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of uses and disclosures we may make of your protected health information, and of other important maters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our Notice, at any time by contacting:

Contact Person:

Sandra Palacios

4566 E. Florence Ave, Ste #8

Cudahy, CA 90201

(323)560-7474

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if your revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent forma, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

AUTHORIZED SIGNATURE

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If this Consent is signed by a personal representative or behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT Include Complete Consent in the patient's chart

*YOU MAY REFUSE TO SIGN THIS ACKNOWEDGEMENT*

I , have received a copy of this office's Notice of privacy Practices.

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FOR OFFICE USE ONLY

WE ATTEMTED TO OBTAIN WRITTEN ACKNOWLEDGEMENT OF RECEIPT OF OUR NOTICE OF PRIVACY PRACTICES, BUT ACKNOWLEDGMENT COULD NOT BE OBTAINED BECAUSE:

I acknowledge I have received From Cesar E. Sanchez, DDS, A copy of the Dental Materials Fact Sheet dated October 2001.

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The following document is the Dental Board of California Dental Materials Fact Sheet. The Department of Consumer Affairs has no position with respect to the language of this Dental Material Fact Sheet; and its linkage to the DCA web site does not constitute and endorsement of the content of this document

The Dental Board of California

Dental Materials Fact Sheet

Adopted by the Board on October 17, 2001

As required by Chapter 801, Status of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet is intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited for the patient's dental needs. It is not intended to be a complete guide to dental materials science.

The most frequently used materials in restorative dentistry are amalgams, composite resin, glass ionomer cement, resin-ionomer cement, porcelain (ceramic), porcelain (fused-metal), gold alloys (noble) and nickel or cobalt-crome (base metal) alloys. Each material has its own advantages and disadvantages and benefits and risks. These and other relevant factors are compared in the attachment matrix titled "comparisons of" Restorative Dental Materials "A Glossary of Terms is also attached to assist the reader in understanding the terms used.

The statements made are supported by relevant, credible dental research published mainly between 1993- 2001. In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993.

The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made.

The durability of any restoration is influenced by the dentist' technique when placing the restoration, the ancillary materials used in the procedure, and the patient's cooperation during the procedure. Following restoration of the teeth, the longevity of the restoration will be strongly influenced by the patient's compliance with dental hygiene and home care, their diet and hewing habits.

Thank you for choosing our dental private practice to receive your dental care. We are committed to the success of your treatment and to help you regain optimal oral health. We hope you understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require you to read, agree to and sign prior to any treatment.

According to your insurance contract, you the patient, rather than the insurance company, is responsible for complete payment for our services. All patients with insurance coverage are required to pay for non-covered services, any deductible, and any copay amount due at the time services are rendered. For patients with dual dental insurance coverage, We will bill both insurances if you have provided us with the necessary information.

Patients insured with plans which we are NOT contracted with, will be required to pay for the first visit in full, and 30% of all treatment provided when services are rendered.

Patients with NO insurance are required to cover first visit in full for services rendered. Payment plans are available and need to be arranged with our Treatment Coordinator prior to start of your dental treatment.

Failure to make payment arrangements or failure by your insurance to pay any claim 60 days after services have been rendered may result in collections and interruption of care.

Our accepted methods of payment are cash, check, Visa, Master Card, Discover Card or Care Credit.

It is the patient's responsibility to verify their benefits, and to inform our receptionists of any changes to your insurance coverage and to present a valid ID card, and insurance identification.

Again, thank you for trusting us with your care. If you have any questions regarding financial arrangements, and payment options, please contact our insurance department.

I HAVE READ, UNDERSTAND AND AGREE TO THE PROVISIONS OF THIS POLICY

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A professional support system:

• My staff is an integrant part of this practice. They have been professionally trained to perform many of the services that you will need. Please feel free to ask they or myself any concern regarding your dental treatment at any time. We welcome you questions!
• Depending on your needs, your appointments will vary In time. You may be scheduled for 30, 60 or 90 minutes or longer. Please arrive to your appointment on time. If you are late, your time will be compromised as there are patients scheduled immediately after your.
• Our office hours have been designed to best fit your schedule. As a courtesy, we will call you to remind your of your appointment, one or two days prior. However, if we are no able to reach you, or leave a message, please know that you are still responsible to keep appointment. IF YOU MUST RESCHEDULE, WE ASK ATLEAST 48 HOURS NOTICE. FAILURE TO DO SO WILL RESULT IN CHARGE OF $25.00 FOR THE MISSED APPOINTMENT.
• Urgent care In time of need. If you have pain, swelling or bleeding or were involved in a sport accident, the doctor will see you as soon as possible. If the occurred after hours, please call our office al (323)560-7474, leave a detailed message with your name and phone number with are code and Dr. Sanchez or a member of our staff will call you Immediately. If you feel you are in a lifethreatening situation, please call 911.

The success of your dental care depends on you:

• Please ask your companions and/or children to wait for you in the reception area while you are being seen by the doctor or staff. We ask parents of children who are patients to also wait in the reception area. This makes communication and patient cooperation easier for the doctor, clinical assistant and patient (even with young children). If needs, we will call in your companion or the parent at the appropriated time.
• It Is important that you follow your home therapy as instructed, take your medications as prescribed, and follow post-op Instructions given after each visit. If you need further clarification or have questions during or after your visit, please feel free to contact us.

We appreciate your understanding and cooperation!

Agreement:

I agree to the above office regulations and understand my commitment to my oral health.

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