Rockingham County Dental Clinic Guidelines and Consent for Treatment Form

All Patients: Are expected to present their Medicaid, Health Choice, or Insurance card at check-in.

New Patients: Please arrive thirty (30) minutes early for patient registration.

Current Patients: Please arrive 15 minutes prior to the appointed time scheduled.

Work-ins: Please be advised you will be seen after scheduled patients.

Late Arrivals: If you arrive more than fifteen (15) minutes late for your appointment, you may be asked to reschedule your appointment so that we will have enough time to complete your treatment. This is up to the discretion of the dentist.

Be Aware: That some dental procedures may run over appointment times due to unforeseen problems that may arise during treatment. We ask for our patients' understanding should this occur.

Cancellations: When canceling an appointment, you must give at least twenty-four (24) hours’ notice. When a patient misses an appointment, we miss the opportunity to care for that patient as well as another patient who could have used that appointment slot.


* First missed appointment: A note will be placed in the chart and the patient verbally reminded of our office policy.
* Second missed appointment: A note will be placed in the chart and the patient verbally reminded of our office policy.
* Third missed appointment: May result in possible dismissal from the dental clinic and a certified letter will be sent to the patient’s home.

If a patient is scheduled with another family member and they both fail to show for their scheduled appointments, the family will no longer be able to schedule multiple appointments on the same day.

Parents/Guardians: Are asked to remain in the lobby during the child’s appointment. Before your child is taken back, our staff will discuss with you any dental problems your child is experiencing and any changes in their medical history.

Patients 17 and under: Must be accompanied by a parent/guardian unless we receive a written consent that is signed and dated by a parent/guardian stating who can present during treatment for the patient. Children are not to be left unattended in the lobby and the dental staff will not be responsible for children left unattended.

Patients 18 and older: Please be advised, should you arrive with a child and have no one to watch your child during your appointment you will be asked to reschedule.


I request and authorize: The dentist(s) of the Rockingham County Health and Human Services (RCHHS) Dental Program to perform any indicated diagnostic procedures, dental surgery, and/or dental treatment which are deemed necessary to diagnose and/or treat the condition(s).

I understand: That dental treatment may be limited in scope and is intended to provide relief from pain, swelling, infection, or injury. I further understand that any additional treatment the patient may require following emergency/urgent care may not be available at RCHHS and in that event, would need to be obtained elsewhere.

I understand: That prior to any treatment I will have the opportunity to ask questions regarding the plan of treatment for this patient. I will also be informed of the potential risks associated with dental treatment (allergic reactions, aspiration, injury to oral structures, post-operative discomfort, temporary or permanent numbness, bleeding, and/or infection). I understand that these are the most common risks and are not necessarily all of the potential risks involved in treatment.

I understand: That if a child is uncooperative during dental procedures by movement of the head, arms, and/or legs, dental treatment cannot be safely provided. During such disruptive behavior, it may be necessary for the dentist/assistant(s) to hold the patient’s hands, stabilize the head, and/or control leg movements. Behavior can also be guided by using praise, explanation, and demonstration of procedures and instruments, or using variable voice tone and loudness. If these measures do not result in the appropriate behavior, I understand that the dental treatment of my child may be discontinued.

All of my questions: Have been answered to my satisfaction and I consent to the treatment and procedures planned. I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated. I understand that if further questions arise about the patient's treatment plan following the initial exam, I may call the clinic for further explanation (336) 342-8273.
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By checking this box I declare that I have read, understand, and agree with the Guidelines and Consent for Treatment stated above. *
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