I hereby give my consent for the dental team of L&Y Dental to carry out an oral examination and/or treatment as deemed necessary after full discussion about my dental health and requirements. The treatment will be provided at L & Y Dental practice in Northwood, UK.
I agree to this information being made available to other healthcare professionals as may be deemed necessary.
Data Protection Notice!
Privacy and Confidentiality:
The confidentiality of patient information is of paramount importance to us. Therefore, we always fully comply with relevant Data Protection Legislation & Guidelines for Medical Confidentially.
The information we collect from you using this form will be used for the purpose of obtaining your valid consent, provision of safe and appropriate dental care as well informing you about our products and services. We will retain this information for 11 years in accordance with the current law. Unless you object or request otherwise, it may be shared with our staff, other healthcare professionals, public authorities such as a Court under a legal obligation request, our partners who help us to provide high class services to you, such as accountants, web developers, dental software providers, email marketing providers, banking and card processing providers. Confidential information is only seen by personnel who need to see it and the team are trained on our policies and procedures to keep patient information confidential. If you have any concerns or requests regarding your personal data usage, please ask our Reception. You may also seek further advice at the Information Commissioner’s Office https://ico.org.uk/
We will respect the wishes of any patient who objects to particular information being shared within our internal team or with others providing care, unless disclosure of such information would be justified in the public interest. If you object to a disclosure of information that we consider essential to the provision of safe care, we either will not be able to refer you for treatment or will otherwise arrange for your treatment to happen without disclosing that information (only if this is possible).
Initial Examination Consultation
In order to secure your booking, you will have been asked to pay a holding deposit of £30 or 40% of the treatment scheduled (whichever is more). The deposit will then be used as a discount from your treatment plan total amount. Failure to attend the consultation at the booked time will result in the deposit being held and not refunded.
We offer you to attend our clinic for a consultation and check-up with full diagnosis provided. At the consultation, if required, X-rays and/or CT scan will be taken of your mouth (without any further cost) to diagnose your case and create your treatment plan. We reserve the right to opt not to take a Panoramic X-ray and/or CT scan based on your medical history or if you recently had one taken during another dental visit within the last six months. This is for your own safety.
Your X-ray and/or CT scan will be kept strictly confidential. If you would like to obtain your small x-rays for out of clinic use, you agree to pay the sum of £11 per x-ray; Panoramic X-ray for out of clinic use, you agree to pay the sum of £65. If you would like to obtain your CT scan for out of clinic use, you agree to pay the sum of £140 per jaw. You must also provide written consent to us before we can send your X-ray or Scan to you or any other medical professional not affiliated with L&Y Dental.
In the event that you miss your appointment without giving us 48 hours’ notice, we reserve the right to hold your deposit as a late cancellation / missed appointment fee or charge you the deposit fee at your next appointment for consultation, if you have not paid already. However, this amount of £30 or 40% of the treatment scheduled (whichever is more) will be deducted from your treatment plan once treatment has commenced.
> L&Y Dental cannot be held responsible to compensate any expenses you incur while travelling to and from your treatment appointments.
> L&Y Dental will not compensate any part of your expenses incurred as a result of re-arranged or cancelled treatment appointments; expenses such as your time away from work, food costs, transport expenses etc.
> In the event that we are forced to reschedule your appointment, or to change the location of your treatment appointment to another current or future location of L&Y Dental, we will not reimburse any additional costs incurred such as travel costs or time away from work.
> L&Y Dental is not liable to pay out compensation that exceeds the cost of treatment.
> L&Y Dental reserve the right to charge deposits for booking future appointments. Deposits are deducted of the total cost of treatment.
Late Cancellations or Missed Treatment Appointments
L&Y Dental reserve the right to charge £30 or 40% of the treatment scheduled (whichever is more) in the event that you miss a treatment appointment without giving us 48 hours’ notice as a late cancellation / missed appointment fee. We confirm your next appointment via email and include the length of time the appointment is expected to take.
Late For Appointments
L&Y Dental understand that some patients travel long distances to get to the clinic and in some cases, being late for an appointment can be unavoidable. If you are more than 15 minutes late, please be aware that you may be asked to reschedule your appointment upon your arrival and also that L&Y Dental reserve the right to charge £30 or 40% of the treatment scheduled (whichever is more) as a missed appointment fee for general appointments and £100 for specialists/experts.
Dentist Late For Appointment
Our dentists do not like running behind schedule, and always endeavour to keep to their daily schedules, to the booked appointment time and to respect patients’ own schedules. However, even with the best of intentions, sometimes our dentists can end up running behind schedule due to unforeseen circumstances such as: extra time being required to treat the previous patient properly, the previous patient being late for their appointment or emergency appointments coming in that need to be given priority. Therefore, you might be asked to wait in the reception area for a period of time before your dentist will be able to see you. If for any reason you unfortunately find yourself in this situation, we kindly ask that you respect that the reasons for the delay are outside of our control.
Doctors For Treatment
During your treatment, and depending on your needs, you will be seen by:
1) A restorative/prosthetic dentist who will take care of all general dentistry treatments and implant prosthesis/restoration;
2) An implant dentist who will provide all surgical treatments;
3) An orthodontic dentist who will provide all orthodontic treatments;
4) A Root Canal treatment expert dentist who will provide most of the Root Canal Treatments;
5) A specialist Oral Surgeon for some oral surgical treatments;
6) An Anaesthetist for sedation procedures;
7) An Expert periodontal dentist for periodontal treatments;
8) A Hygienist for hygienist procedures;
9) An Aesthetic Practitioner for Facial Aesthetics.
Please note that for the benefit of our patients, and for the optimum care and treatment results, we will try not swap your clinicians over (apart from any emergency appointments).
Your Treatment Plan
L & Y Dental will provide you with a detailed treatment plan following your initial consultation, X-rays/CT scan and diagnosis. No part of the treatment plan can be altered without the consent of a member of our dental team. Any change will be confirmed to you in writing and the revised version of your treatment plan will be sent by email. Your Treatment Plan is valid for 3 months.
L & Y Dental are pleased to allow payment for your treatment via Debit Card, Credit Card, Direct Debit or Bank Transfer, provided money is transferred to our bank account in advance.
*We do not accept cheques.
Pay As You Go System
Ahead of booking your first treatment appointment, we will ask for a deposit amounting to £30 or 40% of the treatment scheduled (whichever is more) if it is for general/restorative dentists and 40% of the total cost of the appointment for specialists/experts treatments. Subsequent fees due for dental treatment and dental products are due at the appointment stated on your treatment plan, unless otherwise agreed with prior discussion with our administration team. In the event of the latter, we shall provide you with a revised treatment plan for confirmation.
Where treatment incurs dental laboratory work, 50% of the total fee for laboratory works is due at the appointment where the impressions are taken and the other 50% on the try-in phase.
By signing this document, you agree to the above terms and conditions outlined with full agreement and understanding.