Free Dental Clinic Agreement

This Dental Clinic Agreement ("Agreement") is made and entered into as of [Month Day, Year], by and between:

[Your Company Name]

Address: [Your Company Address]

Phone: [Your Company Number]

Email: [Your Company Email]

("Dental Clinic")

AND

[Client Name]

Address: [Client Address]

Phone: [Client Number]

Email: [Client Email]

("Client")

RECITALS

WHEREAS, the Dental Clinic is a duly licensed dental care provider specializing in various dental services and procedures;

WHEREAS, the Client desires to receive dental services from the Dental Clinic, understanding the scope of services provided;

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, the parties agree as follows:

1. Services Provided

The Dental Clinic agrees to provide the following dental services to the Client:

1.1 Comprehensive Dental Examinations

• Initial Examinations: A thorough review of the Client’s medical and dental history, followed by a comprehensive oral exam. This includes inspecting teeth, gums, jaw alignment, and screening for oral cancer or other abnormalities.

• Periodic Evaluations: Regular check-ups to assess changes in oral health, monitor dental hygiene practices, and detect early signs of dental disease.

1.2 Preventive Care

• Teeth cleaning and prophylaxis.

• Application of dental sealants and fluoride treatments.

1.3 Restorative Dentistry

• Fillings and restorations for decayed teeth.

• Crowns, bridges, and dentures.

1.4 Cosmetic Dentistry

• Teeth whitening services.

• Veneers and bonding procedures.

1.5 Oral Surgery

• Extractions and minor surgical procedures as necessary.

1.6 Orthodontic Services

• Consultations for braces and aligners.

1.7 Additional Services

The Dental Clinic may also provide other specialized dental services, including but not limited to:

• Periodontics (Gum Disease Treatment): Diagnosis and treatment of periodontal (gum) disease, including scaling and root planing (deep cleaning) and gum surgery if necessary.

• Endodontics (Root Canal Therapy): Treatment of infected or damaged tooth pulp to prevent extraction. This involves cleaning and sealing the tooth’s root canal system.

• Pediatric Dentistry: Specialized dental care for children, including preventive care, fluoride treatments, sealants, and management of cavities in primary teeth.

• Sleep Apnea and TMJ Treatment: Dental appliances designed to address conditions such as sleep apnea or temporomandibular joint (TMJ) disorders that cause jaw pain and discomfort.

• Dental Implants: Surgical placement of titanium posts into the jawbone to replace missing teeth. Implants provide a permanent solution for tooth loss, offering both functional and aesthetic benefits.

• Full Mouth Reconstruction: A combination of cosmetic and restorative procedures to rebuild or restore all of the teeth in a client's upper and lower jaws. This is often necessary for clients who have experienced significant oral health issues, trauma, or disease.

2. Appointment Scheduling and Cancellation Policy

2.1 Scheduling

• The Client agrees to schedule appointments in advance via [phone].

2.2 Cancellations

• Cancellations must be made at least [24 hours] before the scheduled appointment. Failure to provide adequate notice will result in a cancellation fee of [$0] to cover administrative costs.

2.3 No-Show Policy

• A "no-show" without prior cancellation will incur a fee of [$0] for the missed appointment.

3. Fees and Payment

3.1 Fee Schedule

• The Dental Clinic shall provide the Client with a Fee Schedule that details the costs of services rendered. The Client acknowledges that these fees may be subject to change and will be notified in advance.

3.2 Payment Terms

• Payment is due at the time of service unless prior arrangements have been made. Accepted payment methods include cash, credit cards, and electronic payments.

3.3 Insurance Verification

• The Client is responsible for verifying their insurance benefits prior to appointments. The Dental Clinic will assist with insurance claims, but the Client is ultimately responsible for any balances not covered by insurance.

4. Insurance and Financial Responsibility

4.1 Client’s Responsibilities

• The Client agrees to provide accurate and up-to-date insurance information and is responsible for any co-payments, deductibles, or other costs that are not covered by insurance.

4.2 Insurance Claims

• The Dental Clinic will submit claims to the insurance provider on behalf of the Client but cannot guarantee coverage. It is the Client's responsibility to understand their insurance policy.

5. Confidentiality

Both parties agree to maintain the confidentiality of all medical records and personal information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

5.1 Patient Rights

• The Client has the right to access their dental records and request amendments if necessary. The Dental Clinic will provide guidance on how to access records.

6. Term and Termination

6.1 Term

• This Agreement will commence on the date first written above and shall continue until terminated by either party.

6.2 Termination

• Either party may terminate this Agreement upon [30 days] written notice. In the event of termination, the Client shall be responsible for payment for any services rendered up to the date of termination.

7. Governing Law

This Agreement shall be governed by the laws of the State of [State], without regard to its conflict of laws principles.

8. Dispute Resolution

8.1 Arbitration

• Any disputes arising out of or related to this Agreement shall be resolved through binding arbitration in accordance with the rules of the American Arbitration Association.

8.2 Notice of Dispute

• The parties shall provide written notice of any dispute and shall attempt to resolve it amicably prior to proceeding to arbitration.

9. Indemnification

The Client agrees to indemnify and hold harmless the Dental Clinic, its owners, officers, employees, and agents from any and all claims, damages, losses, or expenses arising from the Client's negligence or willful misconduct.

10. Entire Agreement

This Agreement constitutes the entire understanding between the parties and supersedes all prior agreements, negotiations, and discussions.

IN WITNESS WHEREOF, the parties hereto have executed this Dental Clinic Agreement as of the date first above written.

DENTAL CLINIC

By:

[Your Name]

[Title]

[Month Day, Year]

CLIENT

By:

[Full Name]

[Month Day, Year]

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