Chandler Dental Clinic
11021 Old Corpus Christi Highway
San Antonio, Texas 78223
In case of emergency, whom do we notify?
Name: ___________________________Phone: ____________
May we thank the person that referred you to us?
OFFICE POLICY STATEMENT
All patients shall be treated with the same level of respect and courtesy. In return, we also ask for the same respect and
courtesy from all patients with regard to scheduling or changing an appointment.
Please read and initial the following statements
______ Your appointment is a time reserved especially for you. We will be happy to change your appointment with an
advanced notification of 24 hours or more during regular business hours (M –F: 9 am- 5 pm). Cancellation on day of
appointment or message left on the answering machine will not be considered adequate advance.
______ If you must change your appointment without advanced notification or if you fail to show for your appointment, please
be aware that this office charges a fee ($25 - $100) based on the amount of time that was scheduled for you.
______ Payment of above fees may be required before you will be allowed to schedule future visits. Multiple missed
appointments or multiple cancellations without advanced notification may require the payment of anticipated
treatment costs prior to treatment without being refundable.
______ This office uses a collection agency to collect on past due accounts. If your account becomes past due, all collection
costs incurred by this office in collecting from you will be your responsibility.
_____ Payment in full is expected at the time of service. The following are choices of payment for you:
2. Check (with Driver’s License)
3. Money Order
4. Care Credit/Dencharge
5. MasterCard/ Visa/Discover/Novus/Bravo
For patients on a limited budget, we can schedule your treatment into smaller