MCDC-48; 02/10
WELCOME TO MCDC
We are honored you have made an appointment with us for yourself, your child, or a person in
your care, and for allowing us to provide your dental care. Our goal is to provide quality services
and continually strive to improve our patients’ experiences. You may receive a phone call from
Press Ganey which is an outside survey company that we have partnered with to receive your
valuable input.
APPOINTMENT REMINDER
MCDC provides a courtesy reminder for reserved appointments approximately one week prior to the appointment,
as well as 1-2 days in advance. Appointment reminders may be sent by voice message, text message, or email. If
you have any questions about these notifications, please call the center directly. We may require a confirmation
response from you that you will be in attendance for your reserved appointment. If we do not receive a
confirmation of your appointment, or we are unable to reach you, your appointment may be cancelled. Please be
sure that the contact information we have on file for you is current and accurate at all times to avoid missing your
courtesy reminder. If we are unable to reach you, your appointment may be cancelled.
BROKEN APPOINTMENT/CANCELLATION POLICY
Regular dental visits every 6 months, including examinations, cleanings, fluoride treatments, dental sealants, and
fillings are important to keep teeth healthy. It is especially important that you keep your appointment! Valuable
time has been reserved for you, or your child’s care. A missed appointment results in lost time which could be used
for another patient waiting to receive treatment.
If you fail to show for a reserved appointment, any appointments you have scheduled will be cancelled. We require
24 hour notice when canceling or rescheduling an appointment that has been reserved for you. Any combination of
failing to give adequate cancellation notice, or not showing up for an appointment, may result in DISMISSAL from
all MCDC center locations.
EMERGENCY CARE
Patients who have been dismissed from the center for either broken appointments, or cancellation reasons, will be
notified by certified letter and will be seen for EMERGENCY care only for 30 days from the date of the dismissal
letter.
MINOR PATIENT APPOINTMENTS
MCDC providers are required to discuss and obtain permission BEFORE providing treatment to all minor patients.
(Children under the age of 18) An adult MUST be present in the center throughout the duration of the child’s
appointment. IF a parent is unable to bring the child to the appointment, there is a consent form that can be signed
to authorize another adult permission to approve treatment plan procedures. Please request this form in advance of
the reserved appointment.
HOME CARE
It is important to maintain regular 6 month checkup appointments, as well as maintain excellent home care and
proper diet. If you do not keep on a regular 6 month schedule, maintain excellent home care and proper diet,
MCDC cannot be held responsible if restorative care fails. Failure of the restoration due to neglect of oral hygiene
and a high sugar/high carbohydrate diet is the responsibility of the patient and not the dentist. Failure of any
restoration within a two year time period, and the required follow up repair or extraction will be at the patient’s
expense. I understand and consent to having restorations completed with these guidelines.
MCDC-48; 02/10
SMOKE FREE CAMPUS
In order to maintain a safe and healthy work environment, MCDC/DCN is a smoke free campus. This means that
employees, patients, and vendors are prohibited from smoking on the grounds or within sight of any MCDC/DCN
building. Smoking is defined as the “act of lighting, smoking, or carrying a lighted or smoldering cigar, cigarette,
e-cigarette, or pipe of any kind”.
BEHAVIOR
Seeking and receiving medical care can be stressful and anxiety provoking. For the sake of all individuals
involved, civil behavior with proper respect, courtesy and manners must be maintained and observed. There is also
a zero tolerance for alcohol, drugs, smoking, or weapons on MCDC property. Individuals who use foul language,
display threatening or violent behavior, or do not comply with our zero tolerance policy, will be immediately
dismissed from all MCDC centers. In an effort to better serve you, cell phone use is not allowed beyond the
reception area.
NOTICE OF PRIVACY
MCDC respects my right to privacy and confidentiality of my personal health information. I acknowledge that I
have been informed of and offered a copy of the Notice of Privacy Practices.
CONSENT TO TREATMENT
I have read the above policy and agree to abide by it.
I HEREBY GIVE CONSENT TO My Community Dental Centers to provide treatment to:
____________________________________, (check one) myself, my child, my ward, those
procedures and treatments, including local anesthesia, which are deemed necessary. I consent to any x-ray,
examination, anesthetic, sedative, or dental treatment rendered under the general, direct or indirect supervision of
the dentist and his/her associates and/or staff members, as he/she may deem necessary.
Information about your appointment may be shared with your medical provider.
This authorization will remain in effect until canceled in writing by me.
I have read the above policy and agree to abide by it.
