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APPLICATION

 

Application for Dental/Medical Services





Dental Applicants Only

I Understand:

  • A 50% or $20 deposit is required at the time of scheduling each dental appointment and a refund cannot be given.
  • My initial visit fee will be $70. $20 is due when scheduling the appointment and $50 is due upon my arrival of the appointment.

All Applicants

I Understand:

  • I am required to pay my office visit co-pay, dental initial visit fee, and/or any other office visit fees each time I have an appointment at Bethesda. If I cannot pay, I may not receive care and may be referred to a patient advocate to be matched up with other resources. All co-pays and fees must be paid in cash or by credit card.
  • Fees for all dental services, labs, x-rays, women’s health, and specialty services are separate. They may be in addition to my medical office visit co-pay, dental initial visit fee, and will vary depending on the test or procedure.
  • If I miss a scheduled appointment and fail to provide at least 24 hours advance notice it could impact my eligibility as a Bethesda patient. Failure to appear at my initial visit or the cancellation of any three appointments can result in my dismissal as a patient.
  • If I cancel an appointment on the same day as that appointment or if I miss an appointment and do not call ahead, I will forfeit any prepaid fees for that appointment.
  • If I am over 10 minutes late, to any appointment, I will not be seen.
  • Specialty services and referrals at Bethesda are limited. They are prioritized for patients where Bethesda is their primary healthcare provider. Not all patients will have access to specialty services and/or referrals.

By clicking the Submit button below, I hereby declare that the above information is true and correct. I know that any false information could jeopardize my eligibility to receive medical and/or dental attention at Bethesda Health Clinic.

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