Jeffrey J. Glaser DDS, MSD, PAPeriodontics and Dental lmplants"Dedicated to quality care for more than 20 years"

WELCOME TO OUR PRACTICE!

We are happy you have selected us to care for your dental needs. Our intentis to serve you in the best possible way. We will be working with you to maintainyour dental health. This involves modern dentistry and personal attention. You willbe actively involved in making your dental decisions. Quality dentistry is not asexpensive as neglect and we will work with you to make modern dentistry affordable.

Our office hours are Tuesday through Friday from 8:00a.m. to 5:00p.m. Dr. Glaser isalso available for dental emergencies after hours by calling the office at (972) 867-3900.

Fees may vary based on severity, difficulty and time spent. As a courtesy to you, wewill submit your dental insurance and accept assignment of benefits to minimize yourup-front out of pocket expense. We do ask that you bring all dental insuranceinformation with you and keep us updated on any changes in your coverage. Theexpense of billing adds to the cost of your dental care, so we ask you to pay yourestimated co-payment at the time the services are rendered unless other financialarrangements have been made in advance. There will be a monthly charge of $7.50 toany remaining and neglected balances after insurance has paid in full.

Our office does everything possible to remain on schedule and provide alltreatment appointed for that day. Unlike a physician's office where several patientsare scheduled at the same time, there is no other patient to take your place when youmiss or cancel an appointment on short notice. Missed appointments affect bothyou and our practice. Therefore, we have a strict cancellation policy. Failure to givea 24 hour notice of cancellation will result in a cancellation fee. This fee may varydepending on the length of your reserved appointment time. lt is understood thatunforeseen emergencies do arise and these situations will be evaluated on anindividual basis. This policy is intended to convey our commitment to our patientsand the mutual respect of their time and dental health care needs.

ln case of a dental emergency, we will make every attempt to see you that day duringregular office hours. lf an emergency occurs after office hours, please call ouroffice for further recorded instructions. No prescription medication will beprescribed over the telephone to patients not of record.

Patient signature Date

3804 W. 15th Street. Suite 100. Plano, fexas75O75.972/867-3900 Answered 24 Hours. FAX: 9721964-2263

Jeffrey J. Glaser DDS, MSD, PAPeriodontics and Dental lmplants"Dedicated to quality care for more than 20 years"

Please advise

medications:

Trade Name

ActoneI

Aredia

Bonefos

Boniva

Didronel

Fosamax

Ostac

Skelid

Zometa

None

the office if you are taking or have taken in the past the following

Generic Name

Risedronate

Pamidronate

Clodronate

lbandronate

Etidronate

Alendronate

Clodronate

Tifedronate

Zoledronic Acid

Please state how ofen and how many milligrams for each drug

Signature Date

3804 W. 15th Street. Suite 100. Plano, Texas75O75.9721867-3900 Answered 24 Hours. FAX: 9721964-2263

Jeffrey J. Claser DDS, MSD, PAPeriodontics and Dental lmplants"Dedicated to quality care for more than 20 years"

I authorize Dr. Glaser to take necessary X-rays to complete a thoroughcomprehensive exam. I understand I am financially responsible for anycharges not covered by my insurance company

Signed

Date

3804 W. 15th Street. Suite 100. Plano, Texas75O75.9721867-3900 Answered 24 Hours. FAX: 972/964-2263

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Signature

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o 2002 American Denbl Associaiion

All Rights Reserved

Reproduction and usc of lhis form by dentisLs and Lhear sbff is permilted. Any olher use, duplicafion or dlsribution of thrs form by any olher party requr.es lhe pr or

writren approval of the American Dcntal Associalion.

This Form is eclucational mly, do6 not coffititute legal adviee, and cove6 mly federal, not state, ls (August 14, 2002).