How to Become a Dental Clinic Patient
The clinic is currently not accepting new patients. We will resume seeing new patients after September 1st. We apologize for any inconvenience this may cause.
Checklist for new patient packets: (We must receive ALL forms to process them into our system)
- Patient History
- Patient Profile (2 pages)
- Consent for routine dental care
- Medical Immobilization Consent
- Acknowledgement of privacy practices
- Copy of Patient's physical
- Insurance information (IPA Card, Dental Insurance Card, Self-Pay information)
Click the button below to download the new patient packet.
All necessary forms must be completed before patients can be entered into the system or scheduled. We will not enter into our system and/or schedule any appointments until we receive all paperwork. No exceptions will be made.
DO NOT fax patient packets back to our clinic. Please mail back ALL completed originals to our office at 275 N. Phelps Ave., Rockford, IL 61108.
Policies regarding appointments
Use of Sedation and/or Medical Immobilization to provide treatment
Fail / No Show Policy
The following policy is the missed appointment policy which will be enforced by the Milestone Dental Clinic.
Rationale:
- Because there are many individuals waiting a long time for appointments
- Because empty chair time is very costly to the program
- Because we expect responsibility and compliance from all of our patients
- Because dental appointments are scheduled for the exact amount of time needed for the treatment
Definitions:
Cancellation - A phone call to cancel an appointment with more than 24 hour notice.
No Show - Failure to come for a scheduled appointment.
Failed - If you arrive late to your appointment and we cannot, in our best judgement, complete the scheduled treatment in a safe, effective and efficient manner.
Policy:
The computer will track all missed appointments. Any patient with 3 missed appointments may become ineligible for the dental program.
Policy on Personnel in Treatment Areas
It is the policy of Milestone Dental Clinic that patients and dental clinic staff members ONLY are allowed in the treatment areas during treatment. There will be no exceptions to this policy. The rationale for this policy is that in order to most efficiently, effectively and safely treat our patients a minimum number of trained dental staff members only need to be present. Additional people in the treatment area adds to confusion, inhibits communication between the doctor and patient, creates possible safety issues (OSHA) and does not allow for the confidentiality of other patients in the clinic (HIPPA). Staff members and family members may be present to seat the patient and then will be asked to leave the treatment area when we are ready to begin treatment. If your assistance is needed at any time during treatment, a dental staff member will come to the reception area and get you. The dentist will speak to you before and or after the appointment, if necessary. If you have specific questions for the dentist please let a staff member know. If you choose not to adhere to this policy we will request that you seek dental care elsewhere. If you would like to discuss this policy further please contact the Clinic Administrator. We appreciate your cooperation with this policy.