Dr. Thomasino and staff are dedicated to providing you with a pleasant visit and results that get you out of pain and on with your daily life. Our administrative staff is ready to help you with questions about our financial policy, wait time and frequently asked questions to assist you with your dental emergency needs.
Please carefully read the following consent and release so that you have a complete understanding of the limited emergency dental services provided by Jacksonville Emergency Dental, P.A. (“Jacksonville Emergency Dental”) and the terms and conditions of your consent to treatment by Jacksonville Emergency Dental and the release of Jacksonville Emergency Dental. You hereby agree to and acknowledge the following:
1. Jacksonville Emergency Dental only provides emergency dental services. The dentists, dental assistants and other dental professionals providing services (the “Dental Professionals”) will only diagnose specific concerns and examine specific areas of the mouth that are specifically requested by you and no other areas of the mouth and no other teeth will be examined. Jacksonville Emergency Dental and the Dental Professionals are not liable for any dental or medical issues arising from other concerns or areas not specifically requested by you.
2. Jacksonville Emergency Dental and the Dental Professionals are not long-term providers for any of your dental care and do not provide complete dental care. The treatment provided by Jacksonville Emergency Dental and the Dental Professionals may only be a short-term treatment to relieve the pain associated with a particular concern or to provide short-term repair until you can receive the care of a general care dentist. Jacksonville Emergency Dental and the Dental Professionals recommend that you seek the treatment of a general care dentist as soon as possible after treatment by Jacksonville Emergency Dental and the Dental Professionals and you agree to do so.
3. Jacksonville Emergency Dental and the Dental Professionals may not be able to treat all of your concerns. Jacksonville Emergency Dental and the Dental Professionals reserve the right to refer any conditions to other dentists and dental professionals, in the sole discretion of Jacksonville Emergency Dental and the Dental Professionals.
4. Some Dental Professionals at Jacksonville Emergency Dental are independently contracted and are not employees of Jacksonville Emergency Dental. The treating Dental Professionals are solely and absolutely responsible for diagnosis and treatment of you. Jacksonville Emergency Dental and any of the Dental Professionals who are not providing treatment to you are not in any way responsible or liable for the acts of the Dental Professionals providing treatment to you, including, without limitation, acts constituting professional negligence.
5. Payment methods include most PPO insurances, cash, credit, debit, Scratchpay Dunn or Scratchpay Arlington (No Hard Credit Check, Quick Application, No hidden fees, Easy monthly payments.) and/or Care Credit (Credit Check Financing). Payment for any and all services is required after treatment is agreed upon but prior to actual treatment.
6. Dental Membership Plans:
Please note: We are a Non-Participating Provider of Medicaid, Medicare and HMO plans.