Healthcare Dental Clinic Contract

HEALTHCARE DENTAL CLINIC CONTRACT

Parties and Effective Date

This Agreement is entered into by and between Clinic Name: , located at Clinic Address: (hereinafter "Clinic"), and Patient Name: , Date of Birth: (hereinafter "Patient"). Effective Date: .

Scope of Services

The Clinic agrees to provide dental services to the Patient as described below. Services may include diagnostic evaluation, preventive care, restorative treatment, endodontics, periodontics, prosthodontics, oral surgery, and associated follow-up care, subject to professional judgment and clinical necessity.

Treatment Consent and Risks

The Patient authorizes the Clinic and its authorized providers to perform the treatments described above and any additional procedures which, in the professional judgment of the provider, are necessary or advisable for proper dental care. The Patient acknowledges that no guarantee has been made as to the result of any procedure.

The Patient has been informed of general and specific risks, including but not limited to infection, bleeding, nerve injury, allergic reaction, postoperative sensitivity, failure of treatment, need for additional treatment, and complications related to medication or anesthesia. The Patient understands the risks and has had an opportunity to ask questions.

I understand and consent to the proposed treatment plan and associated risks: Yes

Financial Responsibility and Insurance

The Patient is responsible for all charges for services provided by the Clinic. Insurance coverage is a contract between the Patient and insurer; the Clinic will assist in filing claims but cannot guarantee payment by an insurer. The Patient agrees to pay any deductible, co-pay, co-insurance, or charges not paid by insurance.

Appointment, Cancellation, and Collections

The Patient agrees to attend scheduled appointments and to provide at least 24 hours' notice for cancellations. Failure to provide timely notice may result in a cancellation fee. Delinquent accounts may be referred for collection; the Patient will be responsible for collection costs, reasonable attorney fees, and interest to the extent permitted by law.

Medical History

HIPAA Authorization and Privacy

The Patient acknowledges receipt of the Clinic's Notice of Privacy Practices and authorizes the Clinic to use and disclose protected health information for treatment, payment, and healthcare operations as described in that notice. The Patient further authorizes release of records to insurance carriers and as required by law.

I acknowledge receipt of the Clinic's Privacy Practices and authorize release of my dental records as necessary for treatment and payment: Yes

Minor Patient / Guardian

If the Patient is a minor or otherwise not competent to consent, the undersigned guardian or authorized representative certifies authority to consent and to assume financial responsibility on behalf of the Patient.

Yes — if yes, Guardian Name:

Limitation of Liability and Indemnification

To the fullest extent permitted by law, the Clinic and its providers shall not be liable for incidental, special, or consequential damages arising from treatment. The Patient agrees to indemnify and hold harmless the Clinic, its officers, employees, and contractors from claims arising from the Patient's failure to follow post-operative instructions or from undisclosed medical information.

Termination and Dispute Resolution

Either party may terminate this Agreement for material breach upon written notice if the breach is not cured within a reasonable period. Disputes arising out of or related to this Agreement shall be resolved first by good faith negotiation. If unresolved, disputes shall be submitted to binding arbitration under the applicable arbitration rules, with venue in the county where the Clinic's primary office is located, unless otherwise required by law.

Miscellaneous

This Agreement contains the entire understanding of the parties with respect to the subject matter and supersedes all prior agreements. Amendments must be made in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in full force and effect.

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