Osseo Family Dental logo 5
  • About Our Practice
    • Meet The Team
    • Meet Dr. Robert Springer
    • Meet Dr. Greg Joiner
  • Dental Services
    • Emergency Dentist
    • Cosmetic Dentist
      • Porcelain Veneers
      • Teeth Whitening
    • General Dentist
      • Gum Treatment
      • Family Dentistry
      • Dental Extractions
      • Dentures – Complete and Partial
      • Dental Fillings, Crowns And Bridges
    • Dental Implant Services
      • Implant Supported Dentures (All-On-Four)
    • Sleep Apnea
    • Root Canal And Endodontics
    • Kid’s Dentist
  • Dental Forms
  • Blog
Menu
  • About Our Practice
    • Meet The Team
    • Meet Dr. Robert Springer
    • Meet Dr. Greg Joiner
  • Dental Services
    • Emergency Dentist
    • Cosmetic Dentist
      • Porcelain Veneers
      • Teeth Whitening
    • General Dentist
      • Gum Treatment
      • Family Dentistry
      • Dental Extractions
      • Dentures – Complete and Partial
      • Dental Fillings, Crowns And Bridges
    • Dental Implant Services
      • Implant Supported Dentures (All-On-Four)
    • Sleep Apnea
    • Root Canal And Endodontics
    • Kid’s Dentist
  • Dental Forms
  • Blog
(763)425-2626
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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking

Are you under a physician's care now?*
Have you ever been hospitalized or had a major operation?*
Have you ever had a serious head or neck injury?*
Are you taking any medications, pills, or drugs?*
Do you take, or have you taken, Phen-Fen or Redux?*
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
Are you on a special diet?*
Do you use tobacco?*
Do you use controlled substances?*
Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Do you have, or have you had, any of the following?*
Have you ever had any serious illness not listed above?*
Are you...

FINANCIAL POLICY

Welcome to Osseo Family Dental Clinic! Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining important health treatment. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the payment options listed below:

Mode of Payment*

* For dental work over $200.00. a current credit card number and expiration date is required. We will not carry an account balance past 90 days.

As a courtesy to our patients, all insurance forms wlll be filed on behalf of the patient by our office, free of charge.
Please be advised that regardless of your dental coverage, our Clinic relies on you for settling your account.
We have eliminated costly bookkeeping and billing fees by implementing the above policy. The savings is reflected in our fee schedule, thus maintaining reasonable fees for our patients.
Broken Appointment Policy: There will be a $50 per appointment hour chair charge for failed appointments or appointments cancelled with a less than 24-hour notification.

COVID-19 SCREENING FORM

By signing this form I consent to the following:

1. I have not had or have been diagnosed with COVI D-19 in the last 14 days.

2. I do not have any of the following symptoms linked to COVID-19 listed below:

  • Fever
  • Fatigue
  • Loss of taste/smell
  • Blueish lips/face
  • Muscle pain

  • Dry Cough
  • Trouble Breathing
  • Shortness of Breath
  • Chills
  • Headache/sore throat

3. I have not been in contact with anyone sick and/or confirmed to be positive with COVID-19.

4. I have not traveled to any regions affected by COVID-19 in the past 14 days.

Consent*
*

HIPAA Acknowledgement

I understand that I have certain rights to privacy regarding my protected health information.

These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g., my insurance company);

I have also been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA.

I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

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Copyright © 2022 Infinite Dental Marketing

Opening Hours:
Monday 10am – 7:00pm

Tuesday 7am – 3:00pm

Wednesday 7am – 3:00pm

Thursday 7am – 3:00pm

Friday 7am – 1pm

Phone: (763) 425 – 2626
Email: info@osseofamilydental.com
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Address: 30 Central Ave, Osseo, MN 55369