PRESENT HEALTH (please specify where appropriate)
APPOINTMENTS: Please give a minimum of 24 hours notice if an appointment must be cancelled. This
will enable us to see patients who are waiting for appointments at an earlier time.
Patients are personally responsible for payment of fees. We will prepare the necessary reports to enable
us or you to be reimbursed by your insurance company. Please note: the degree of
reimbursement varies with the company and type of coverage
I authorize release to my Insurance Company's plan administrator, any information necessary to support
claims or predeterminations submitted by you the patient or on your behalf by this office.
I authorize you to request or furnish any dental or medical records to a dentist or physician which would
help in the diagnosis and treatment of my condition.
review at any time.
WESTWOOD/STARWOOD DENTAL CANCELLATION POLICY
Westwood Dental requires a minimum of 24 hours to cancel your reserved appointment time. Failure to
do so, may result in a $75.00 cancellation fee.