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*Insurance is not required, but Jacksonville
Emergency Dental (JED) will assist in providing insurance codes for self filing. Payment methods are limited to cash or credit
card and must be rendered after treatment is agreed upon but, before treatment begins. 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. The 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 are limited strictly
to cash or credit card. Payment for any and all services is required after treatment is agreed upon but prior to actual treatment.
We welcome you to Jacksonville Emergency Dental! Florida Lic. #: DN-16459
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