Thank you for choosing Penn Dental Medicine!

General Information: Penn Dental Medicine (also referred to as “PDM”) is a teaching institution and patients accepted into the teaching program will have their treatment supervised by members of the PDM faculty. All care and treatment will be provided in a competent and respectful manner. PDM is a teaching institution, and therefore, treatment may require more time than treatment performed in a private dentist office setting. Most appointments at PDM require approximately one to four hours. Patients are expected to be available once and sometimes twice a week.

Penn Dental Family Practice (also referred to as “PDFP”) provides patients in-depth experience and knowledge in the art and science of dental medicine. PDFP patients benefit from a team of experts who practice using the leading techniques in patient care. Penn Dental Family Practice includes practitioners who also teach the next generation of dentists and practice at Children’s Hospital of Philadelphia, Penn Presbyterian Medical Center, and the Hospital of the University of Pennsylvania.

• Emergency Dental Care: Emergency dental treatment is intended to provide relief of severe pain and infection for individuals in acute need.
• PDM Patients: As a COMPREHENSIVE CARE patient, you have access to a 24-hour dental emergency service. There is a charge associated with this service. After-hours emergency: Monday through Friday between 4:30 p.m. and 8 a.m., weekends and PDM holidays. Patients experiencing an after-hours emergency must call 215-898-8961.
• PDM Patients: As a COMPREHENSIVE CARE patient, you have access to a 24-hour dental emergency service. There is a charge associated with this service. After-hours emergency: Monday through Friday between 4:30 p.m. and 8 a.m., weekends and PDM holidays. Patients experiencing an after-hours emergency must call 215-898-8961.

Consent to Dental Care: I hereby present myself for care and/or admission at the location of Penn Dental Medicine listed above and voluntarily consent to care including routine diagnostic procedures and dental treatment by authorized agents or employees of Penn Dental Medicine. I acknowledge that no guarantees have been made to me regarding the results of the care provided at PDM or PDFP. I understand that Penn Dental Medicine is part of the University of Pennsylvania,
which is a teaching institution, and agree that those involved in training programs may participate in my care

Patient Access to Information and Consent to Treatment: As a patient, I understand that I will have access to current and complete information about my condition and will, unless otherwise specified, receive continuity of treatment, be provided an estimate of the cost, and receive dental care according to a properly sequenced plan of treatment. Before receiving treatment, my dental care provider or hygienist will discuss with me the procedure(s) that he/she recommends I undergo, and I will have an opportunity to ask any questions I may have before I decide whether to give consent for the procedure(s) to be done. All dental procedures may involve risks, including the risk of an unsuccessful result and/or complications, and that no guarantee has been made as to a result or cure. I have the right, at all times, to be informed of any such risks, as well as the nature of the procedure, the expected benefit, the availability of alternative methods of treatment, and the
risks of no treatment. Dental radiographs will be made as necessary and appropriate for examinations, diagnosis, consultation, and treatment. I have the right to consent to or refuse any proposed procedure at any time prior to its performance.

Financial Responsibility: I understand that I will be charged for treatment according to the fee schedule in effect at the time of service. A fee estimate will be provided to me prior to beginning treatment and I understand that I must be prepared to pay for services as they are provided. I understand that for procedures such as a denture, bridge or crown, a portion of the fee is required before starting treatment and that the entire payment must be made before such treatment is
finished. I agree to be responsible for all charges for dental services and materials not paid by my dental plan.

By signing this consent form, I authorize payment of dental benefits otherwise payable to me, directly to Penn Dental Medicine and to the extent permitted under applicable law, I authorize the release of any information relating to the claim to my dental plan. I understand that if my account is referred to collections, I will be responsible for the outstanding charges and all collection expenses.

Dental Medical Records: I understand that the dental medical record, radiographs (x-rays), photographs, videos, audio/digital recordings, models, and diagnostic aids relating to my treatment are the property of Penn Dental Medicine. Penn Dental Medicine may use and disclose and may acquire from other health care providers my personal health information as allowed by law, including but not limited to, for the purpose of providing health care, processing payments, and
running PDM operations. I understand that Information acquired about my treatment for HIV/AIDS, substance use disorder and behavioral health treatment is subject to special privacy protection under state and/or federal law.

Communications: To improve your experience with us, we offer you the opportunity to receive phone call, text, and email messages related to your care and treatment at Penn Dental Medicine including, but not limited to appointment confirmations, payment reminders and other important information. I understand that texting and email are not 100% secure. Message and data rates may apply to text messages.

Keeping Your Appointment: I understand that failure to keep my appointments for whatever reason could result in the discontinuation of treatment. There may be a charge for failing to keep an appointment or cancellation with less than 24 hours’ notice.

Discontinuation of Treatment: I understand that Penn Dental Medicine reserves the right to discontinue dental treatment whenever it is considered advisable and in the best interest of PDFP, me or the PDM teaching program. I understand that should treatment be terminated, any remaining credit balance for services not yet provided will be refunded to me.

I understand that if I have any complaints which cannot be resolved at the student or faculty level at PDM or with the Practice Administrator at the PDFP, I may request an appointment by contacting:

Penn Dental
Office of the Patient
Advocate 240 S. 40th
Street Philadelphia, PA
19104
Phone: (215) 573-4742
Email: PDMPatientAdvocate@dental.upenn.edu

AUTHORIZATION TO DISCLOSE INFORMATION

To fulfill the mission of Penn Dental Medicine, we are required to train new dentists, ensure our students get certified in their specialty areas, share the dental knowledge with others in the profession, and contribute to the professional literature. Toward this end, students and faculty of the PDM often are required to present dental cases of interest to the professional community at conferences and to bodies involved with professional accreditation. On occasion, these case studies may be published in journals of professional stature. In some instances, these case presentations involve protected health information. By signing this authorization, you agree to let clinical care providers of Penn Dental Medicine disclose the protected health information listed for the purposes of such case presentations.

1. I understand that Penn Dental Medicine providers wish to disclose my protected health information for case presentation purposes. Specifically, they wish to present a description of my dental condition; information about my general health; demographic information concerning my age, ethnicity, and gender; and/or a full-face photograph. No other protected health information than that listed in this point will be permitted for case presentation
   purposes as a result of this authorization. My name will never be disclosed.
2. The only individuals authorized to disclose my protected health information for case presentation purposes are Penn Dental Medicine providers.
3. The only individuals authorized to receive my protected health information pursuant to this authorization are:
   • members of recognized professional dental accreditation bodies, and or
   • attendees of professional dental meetings, one purpose of which is the presentation of dental case studies, and or
   • compendia of proceedings of professional dental meetings which may be distributed to members of the sponsoring dental organization, and or
   • subscribers to journals published for the dissemination of new dental knowledge
4. This authorization is limited to disclosures of my protected health information described above for the purpose of dental case presentation and/or publication, by students, residents, and the faculty of the PDM and clinical care providers of PDFP
5. I understand that I have the right to revoke this authorization at any time. Penn Dental Medicine is unable to retract any disclosures made prior to the revocation. I further understand that such revocation must be in writing and that limitations to this revocation are included in the Notice of Privacy Practices
6. Penn Dental Medicine may not condition treatment on my signing this authorization.
7. I understand there is a potential that the information disclosed as a result of this authorization may subsequently be disclosed by the recipient in a manner that is not protected by Federal Law.