Call: (505) 884-8000
Text number: (505) 886-2939
Mon-Fr: 9:00 AM – 4:00 PM
6800 MONTGOMERY BLVD NE # C Albuquerque, NM 87109
Welcome and thank you for selecting Sandia Dental Care and our dental health care team.
We strive to provide our patients the best possible dental care. If you have any questions or need assistance, please ask us. We will be happy to help.
Responsible Party Information
(Skip if this portion does not apply to you)
In Case of Emergency
Dental Insurance Information
Although dentistry treats primarily the area in and around your mouth, your mouth is a part of your entire body. We believe in the importance of treating the patient holistically. Therefore, other health problems or medications that you may be taking could be relevant to your dental care. Thank you for answering the following questions.
Are you allergic to any of the following?
Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.
To the best of my knowledge, I have answered the questions on this form accurately. I understand that it is my responsibility to inform the dental office promptly of any changes in overall health or medical status.
Are any of your teeth sensitive to:
Have you ever had:
Have you ever experienced:
Thank you for choosing Sandia Dental Care for your dental care needs. We believe it’s important to share our policies with our patients in advance. As always, we are pleased to answer any questions you may have or explain the treatment process in greater detail. Please read thoroughly and sign below indicating that you understand these policies and agree to comply with them. We welcome your questions and comments and are committed to providing excellent dental care services to all our patients. We appreciate the confidence you place in us.
We may accept assignment of insurance benefits from your primary carrier after your second visit. Your coinsurance portion, including any deductible, is due at the time of service. Your co-insurance or co-payment is calculated on the information provided by your carrier at the time of estimate. Please note that your insurance policy is a contract between you and your insurance company. We accept assignment of benefits as a courtesy to our patients. Any claim not paid by your insurance carrier within 60 days will be billed to the patient.
Please help us serve you and our other patients better by keeping your scheduled appointments. Our answering machine does not accept cancellations. We prefer to speak with you in person and require 24-hour advanced notice to reschedule or cancel appointments. If you DO NOT give a 24-hour notice to reschedule or cancel your appointment there WILL BE a $60.00 fee charged to your account.
In the event payments are not received by agreed upon dates, a 1.75% late charge (21% APR) may be added to the delinquent account. Attorney’s fees and collection fees incurred to settle any outstanding balance are the responsibility of the patient. There will be a $25.00 fee for any returned check.
Methods of Payment
Payment for services is expected at the time of treatment unless prior arrangements have been made. For your convenience we accept: Cash, Check, Credit Card, Care Credit (MasterCard, Visa, Discover, and American Express).
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*You May Refuse to Sign This Acknowledgement*
have received a copy of this office’s Notice of Privacy Practices.
Office purposes only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
Sandia Dental Care
6800 Montgomery Blvd. N.E. Suite C
Albuquerque, New Mexico 87109
Phone (505) 884-8000
DENTAL TREATMENT CONSENT FORM
For your convenience, we make available this generalized dental consent form for you to review and sign. Please do not hesitate to ask our dental staff any questions you may have.
DRUGS AND MEDICATIONS
I understand that local anesthetics, antibiotics, and pain medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and or anaphylactic shock (severe allergic reaction).
PERIODONTAL LOSS (TISSUE & BONE)
I understand that serious gum problems can lead to bone infection or bone loss and that it can lead to the loss of my teeth. Alternative treatments include gum surgery, replacement and or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.
ENDODONTIC TREATMENT (ROOT CANAL)
I realized there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).
CROWNS, BRIDGES AND CAPS
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap including shape, fit, size, and color will be before cementation.
REMOVAL OF TEETH
If the teeth are savable or restorable, the alternatives to removal of teeth are root canal therapy, crowns and periodontal surgery. I understand removing teeth does not always remove all the infection, if present and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection dry socket, loss of feeling in my teeth lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time (days or months) ,or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.
DENTURE, COMPLETE OR PARTIAL
I realize that full or partial dentures are artificial, constructed of plastic, metal, and or porcelain. The problems of wearing these appliances include looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visits. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.
CHANGE IN TREATMENT PLAN
I understand that during or following treatment it may be necessary to change or add procedure because of conditions found on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedure.
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for my minor child or myself. I have had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction.
Mon – Fr: 9:00 AM – 4:00 PM
Phone: (505) 884-8000
Text number: (505) 886-2939 (texts are returned during business hours only)
Address: 6800 MONTGOMERY BLVD NE # C, Albuquerque, NM 87109
© 2019 by Sandia Dental Care Themespride