Service Agreement and Informed Consent

Service Agreement and Informed Consent
This Service Agreement (“Agreement”) governs your use of the services of Azar Sona
Saeidi DMD Inc., D.B.A. Soothing Dental (“Soothing Dental,” “Us” or “We”). By
engaging our services, you agree that you have read, understand and consent to this
Agreement:
Service Acceptance
1. Patient has the legal right and ability to: (i) enter into this Agreement, (ii) receive
Dental Services for personal benefit or the benefit of their (his/her) legal minor children,
and (iii) abide by the obligations, including the Terms and Conditions, set forth in the
Agreement.
• Patient acknowledges that s/he is making an informed decision to enter into
this Agreement and has been given all necessary and relevant information to make that
decision.
• Patient agrees by accepting the Dental Services provided by Us that s/he
and/or his/her minor child, if applicable, are a patient of the Dental Practice, and are
entering into a patient- provider relationship with the dental professional(s) that the
Dental Practice assigns to their care.
2. Patient hereby authorizes the Dental Practice to administer such medications
and perform such diagnostic, photographic and therapeutic procedures as may be
necessary for proper dental care, in accordance with the Consent to Treatment, set
forth in this Agreement.
3. Patient agrees to permit Us to use and disclose his/her health information with (i)
any Dental Coverage carrier identified by them, and (ii) any healthcare
professionals in the course of treatment, or as otherwise required by law.
4. Patient agrees to update the Dental Practice of ANY changes in his/her medical
or dental history whether they believe that to affect dentistry and/or their treatment
or not.
5. Patient agrees that any prescription of medication for dental
treatment that s/he receives from the Dental Practice shall be solely for their
personal use or the use of their legal minor child that is our patient.
6. Patient agrees to be financially responsible for the cost of Dental Services to
be rendered; and if s/he has a Dental Coverage, Patient agrees to authorize
Soothing Dental to accept payments directly from the corresponding dental carrier
for benefits otherwise payable to Patient.
7. Patient understands that there are potential risks associated with receiving
Dental Services including but not limited to the potential risks of infections, or
breaches of privacy of personal information.
8. Patient agrees to fully and carefully read all information provided to them from
Soothing Dental on their care, any follow-up instructions, or prescribed medications.
9. For the safety of patients, staff and doctors, Soothing Dental is equipped with a nonconcealed video surveillance system, and all calls are being recorded & monitored.
Video & audio data is secured with reasonable efforts for Patient’s privacy. In certain
circumstances, Soothing Dental may share the data with the police and/or other entities
as required by law. Patient understands that surveillance may be conducted in all areas
such as waiting areas, examining and treatment rooms and business offices. Soothing
Dental retains ownership of the surveillance recordings. The recordings are not
considered treatment records and will not be included when transferring dental records
to any other medical or dental provider, insurance company or to a parent/legal
guardian.
Consent to Dental Treatment
1. TREATMENT TO BE DONE: Patient understands and consents to have treatment
done by Soothing Dental. There are risks and benefits associated with any procedure
that is being performed. These treatments include, but are not limited to x-rays (2-D or
3-D), cleanings (different types), local anesthesia, periodontal treatments, fillings,
crowns, bridges, extractions, orthodontics, root canal treatments, implants placement or
removal, full or partial dentures, various whitening procedures, Botox injections, night
guards or retainers, etc.
2. DRUGS AND MEDICATION: Patient understands that antibiotics, analgesics,
anesthetics and other medications can cause allergic reactions, presenting as
redness, swelling of tissues, pain, itching, vomiting, and /or anaphylactic shock,
etc.
3. CHANGES IN TREATMENT PLAN: Patient understands that during treatment, it
may be necessary to modify or add procedures because of conditions found while
working on a teeth or mouth; for example, root canal therapy following routine
restorative procedures may be needed, or fillings may include more surfaces that
initially anticipated. Patient gives permission to the Dentist to make any/all changes
and additions to his/her treatment plan as necessary for Patient’s benefit in real
time. And Patient is fully liable for the fees incurred for such changes as the recipient
of the treatment and service. REMOVAL OF TEETH: Patient understands that
sometimes there are alternatives to tooth extraction, such as root canal therapy or
periodontal surgery, etc. And Patient agrees to completely understand these
alternatives, including their risks and benefits prior to authorizing the Dentist to
remove a tooth. Patient understands removing teeth does not always remove all the
infection either, if present, and it may be necessary to have further treatment done
beyond just the extraction. Patient understands the risks involved in having teeth
removed, some of which are pain, swelling, spread of infection, dry socket, loss of
feeling to teeth, lips, tongue and surrounding tissue that can last for an indefinite
period of time or at times result in a fractured jaw bone. Patient understands that
s/he may need further treatment by a specialist if complications arise during or
following treatment, the cost of such visits or treatments is his/ her responsibility, and
not that of the Dental Practice or the Dentist.
4. CROWNS (CAPS), VENEERS, BRIDGES: Preparing a tooth for a restoration
means cutting into the tooth structure; and that may irritate the nerve tissue in the center
of the tooth, leaving the tooth feeling sensitive to heat, cold, pressure or chewing.
Treating such irritation may involve using special toothpastes or particular mouth rinses
in minor cases, or root canal therapy and in extreme cases could even result in needing
an extraction. Furthermore, Patient understands that sometimes it is not possible to
match the color of a new restoration to the existing natural teeth or other existing crown
or veneers. Patient further understands that s/he would be required to wear temporary
restorations, which may come off easily and that s/he must be careful to ensure that
they are kept on until the permanent restorations are delivered. It is the Patient’s
responsibility to return for the permanent cementation within 30 days from tooth
preparation, unless otherwise directed, as excessive delays may allow for tooth
movement or decay formation, which may necessitate a remake of the crown or bridge
for instance. Patient understands that there will be additional charges for remakes due
to the delay in scheduling and attending the appointment for permanent cementation of
a restorations should it not fit because of the timing of the appointment and movement
of the teeth. Furthermore, Patient understands that the final opportunity to make
changes in his/her new crown/veneer or bridge (including shape, fit, size, and color) will
be prior to the permanent cementation. And subsequent change requested after
cementation will incur a new extra charge as the restoration will need to be remade and
is not salvageable/usable anymore. And if a new restoration would mean needing a new
retainer or a new night guard for instance, that is a separate treatment and will incur its
own costs.
5. ENDODONTIC TREATMENT (ROOT CANAL): Patient understands that there is
no guarantee that a root canal treatment will save a tooth. Patient understands that
endodontic instruments are very fine and stresses vented in their manufacturing
along with the treatment process can cause them to break during use. Patient
understands that referral to an endodontist for additional endodontic treatment may
be necessary following any root canal treatment, and Patient agrees that s/he is
responsible for additional costs for treatment performed by an endodontist. Patient
understands that a tooth may require extraction in spite of all efforts to save it.
6. PERIODONTAL DISEASE: Patient understands that periodontal disease is a
serious condition involving gum and bone inflammation and/or loss, and that it can lead
to the loss of one’s teeth. Patient understands the alternative treatment to correct
periodontal disease via periodontal surgery, could be tooth extraction with or without
replacement of such teeth.
7. FILLINGS: Patient understands that care must be exercised in chewing on fillings,
especially during the first 24 hours to avoid breakage of the filling and also to not bite
onto the soft tissue that may be numb/anesthetized. Patient understands that a more
extensive restoration, such as filling or a crown may be required, as additional decay or
fractures may become evident after initial excavation of a decay. Patient further
understands that filling one’s tooth may irritate the nerve tissue creating sensitivity and
treating such sensitivity could require root canal therapy when irreversible. Patient also
understands that there is no guarantee as to how long restorations last in the mouth as
the mouth is a very dynamic environment, and anything from clenching, grinding to
sleep apnea, nail biting, or even regular chewing cycles could affect the longevity of
such restorations.
8. ORTHODONTICS: Patient understands that orthodontic treatment requires time
and may need revisions to ensure that proper occlusion/bite and aesthetic results are
achieved. Furthermore, Patient understands that an “ideal” outcome may not be
achieved as the alignment of the teeth is limited by the bone and musculature present
as well as one’s compliance. Furthermore, if no retainers are worn by Patient after the
completion of orthodontics, results will not be permanent. Should be also noted that
teeth or existing restorations may incur damage during such treatment due to the forces
applied.
9. WHITENING PROCEDURES: Patient understands that whitening protocols are
cosmetic and the results are not guaranteed. Care and effort will be taken to ensure that
Patient is pleased with the outcome, however, the change is not a permanent change in
the shade of the teeth. And such treatments could render the teeth sensitive, and there
could be visible difference in shade between various teeth thereafter.
10. Patient is provided a copy of the Dental Board of California’s Dental Materials
Fact Sheet as a part of this document.
11. Patient understands that dentistry is not an exact science and that no dentist can
guarantee results.
12. Patient hereby authorizes any of the doctors or dental auxiliaries to proceed with
and perform the dental restorations and treatments as explained to him/her.
13. Specialist is a licensed practitioner of dentistry within the state of CA and practices
as an Independent Contractor within Soothing Dental from time to time. Services
rendered by them are guaranteed by the Specialists. Terms and conditions of their visits
are to be observed by the Patient when presented independently.
Terms and Conditions
A. Patient Responsibilities:
1. Patient is responsible for providing accurate information about themselves to
Soothing Dental (for instance during verbal communication on the phone or in person,
or in writing such as information entered in any of the dental/medical history forms). And
s/he is to update any changes such as address or phone number, medical status or any
insurance coverage, etc.
2. Patient agrees to follow all recommendations, protocols and other instructions
provided by Soothing Dental.
B. Dental Services provided by a Dental Practice:
1. Dental Practice will offer to the Patient and perform Dental Services as
determined clinically necessary in the sole professional judgment of a dental
professional of the Dental Practice.
2. Dental Practice shall establish charges to be paid by Patient in accordance
with the Dental Coverage or Discount Plan/Offer selected by the Patient (then referred
to as Member).
3. Dental Practice shall bill and collect for all Dental Services provided to the
Patient by the Dental Practice.
C. Privacy and Security:
Soothing Dental respects the Patients’ privacy and takes privacy very seriously.
By accepting this Agreement, you consent to permit Soothing Dental to use and
disclose your personally identifiable information, including health information, provided
or developed while you are a Patient and receiving Dental Services.
D. Electronic Health Record:
1. Soothing Dental maintains an Electronic Health Record (“EHR”) system and
creates a record for each Patient (“Record”) and stores them in accordance with
relevant dental record keeping that the state requires.
2. Patient’s Record is created to store Patient’s Personal Health Information
(PHI), including health conditions, allergies, relevant dental history, and medications.
Information provided as part of Patient enrollment, Patient intake, or consultation with a
Soothing Dental representative, if appropriate, may be maintained in Patient Record
and relied on by our clinicians in providing care to Patient.
E. Password and PIN:
Patients may access Patient information on the Soothing Dental Site only
through the use of a password and/or PIN selected by them.Patient is solely
responsible for maintaining the confidentiality of their password and/or PIN, and for all
activities that occur under their password and/or PIN. Patient agrees to prohibit anyone
else from using the password and/ or PIN, and to immediately notify Soothing Dental of
any unauthorized use of the password or other security concerns of which Patient
becomes aware.
F. Financial Policy:
1. Soothing Dental will provide Patient with an estimate for any recommended
treatment. Estimates are not a guarantee of payment by Dental Coverage carriers. And
they are subject to change.
2. Soothing Dental reserves the right to automatically charge 50% of the
Patient’s estimated portion in order to reserve an appointment for treatment. The
remainder of the balance is due on the day of treatment unless otherwise agreed upon.
3. Soothing Dental provides financial options for those who wish to have
payment plans, if they qualify. The payment options are subject to the discretion of
Soothing Dental.
4. Soothing Dental accepts all PPO dental plans/coverages, and no HMOs or
state-funded programs such as MediCare/MediCal/DentiCal, etc.
5. For Patients with Dental Coverage, Soothing Dental will:
o Research their dental insurance plan to advise the patient of the
availability of their benefits. This research is subject to the timely furnishing
of the needed information by the Patient. It should be noted that any pending
claims from any other office or provider will not show in our research and is
the responsibility of the patient to inform the office of such situations. If
pending claims from another office leaves no available benefits without
Soothing Dental’s knowledge, covering the cost of the rendered services is
the sole responsibility of the Patient.
o Submit a claim to the insurance carrier on behalf of the
patient as a courtesy.
o Follow the American Dental Association’s guidelines for coding
procedures and submitting insurance claims.
o Will Resubmit/Appeal any claim that has been denied or
processed incorrectly as a one time courtesy to the patient.
o Upon request, will submit a Preauthorization to the insurance
carrier before treatment is scheduled. However, it is noteworthy that
preauthorization is not a guarantee of payment by any insurance
carrier; it is an estimate by the carrier and is always subject to their
approval of the claim after the claim submission.
6. If Patient chooses to use a Dental Coverage where Dental Practice is listed as
an in- network provider, Soothing Dental will submit a claim and accept payments in
accordance with the coverage requirements and agreed-upon fee schedule with the
carrier. Patient agrees to pay any necessary copays or deductibles as required by
Dental Coverage still. If Patient’s Dental Coverage denies payment for any Dental
Services rendered, Patient understands and agrees that Patient will be responsible for
the cost of such rendered treatment.
7. If Patient chooses to use Dental Coverage and the Dental Practice is listed as
an out- of- network provider, Soothing Dental still will submit a claim and accept the
payment on behalf of the Patient according to Soothing Dental’s UCR fee schedule.
Soothing Dental will bill the balance between the billed fees and the amount of the
payment received. And Patient agrees to pay any necessary copays or deductibles as
required by Dental Coverage, as well as any remaining balance between the amount
paid by Patient and the Dental Coverage against the amount billed for the charges
(UCR fee schedule). If a Patient’s Dental Coverage denies coverage for any Dental
Services, Patient understands and agrees that the Patient will be responsible for
payment of any amounts not covered by the Dental Coverage in full.
8. If a Patient has a Dental Coverage, s/he also authorizes payments
directly to Soothing Dental from any Dental Coverage of any insurance benefits
otherwise payable to Patient.
9. In the event that a Dental Coverage carrier would retract a payment for
services rendered, for any reason, Patient will be responsible for the retracted amount
payment immediately. Patient can resolve the underlying issue with the Dental
Coverage carrier directly on his/her and on their own time.
10. Soothing Dental accepts various forms of electronic payment in addition to
cash or cheque for services being rendered. Soothing Dental currently accepts
electronic payments made by credit or debit card, prepaid credit cards or health-savings
accounts (HSA/FSA). Soothing Dental shall retain information pertaining to electronic
payment methods for use on future charges, payment of unpaid balances, or payment
of any cancellation or other fees incurred.
11. A monthly service charge of 2% will be added to any balance that is not paid
within 30 days of notice.
12. If Patient fails to remit three consecutive monthly payments (referred to as a
“missed payment”), or if Patient remits three consecutive late payments, (“late payment”
means the payment remitted after 11:59 pm on the payment due date), or if Patient
remits three consecutive partial payments (“partial payment” means the payment was
less than the account balance due to Dental Practice in a given month), or any three
month combination thereof, Patient shall be considered in Default of this Agreement and
Dental Practice has the exclusive right and authority to exercise any or all of the
following remedies:
(1) immediately terminate the Services Agreement or Dental
Coverage Agreement,
(2) send any and all outstanding amount(s), inclusive of
monthly payments, service charges, late payments and interest
to a third party collection agency for purposes of collection which
will adversely affect the Patient’s credit score,
(3) require advanced payment in full for all procedures
following the Three Month Default, prior to rendering treatment
(collectively referred to as “Default Remedies”).
If Dental Practice exercises its right to terminate the Agreement, the Patient
/Member will be subject to the Dental Practice’s UCR fees set by the Practice’s fee
schedule for all procedures and treatment following the Three-Month Default
period. UCR fees are subject to change at any time.
If Dental Practice does not exercise the Default Remedies following a ThreeMonth Default period, Dental Practice does not waive its right to exercise Default
Remedies for any subsequent Three-Month Default of Member or Patient.
In addition to the aforementioned remedies, Dental Practice shall charge a
$500 fee on any Patient/Member account when an initial Three Month Default occurs
which shall be billed to the Member who is financially responsible for the account in
Default, for purposes of compensating the Dental Practice for additional costs
expended to collect on Patient or Member’s outstanding account.
Dental Practice shall charge a fee of $100 on any Patient or Member account
for each month following the initial Three-Month Default, that there is a missed
payment, late payment or partial payment on Patient’s /Member’s account.
14. If a Member or Patient’s balance on an invoice for Dental Practice services
or Membership Services becomes past due by thirty (30) days or more, on or after the
thirtieth day that such balance is past due, the following will occur:
o a four percent (4%) monthly late fee shall accrue on all amount(s)
past due on the thirty-first (31) day or more, and
o the Dental Practice reserves the right to run the credit card or other
electronic payment method on file with the account, for the full balance,
including fees and interest, that is thirty (30) days past due, and Patient will
receive confirmation of payment in the form of a receipt or transaction
confirmation.
15. In the event that a Member’s or Patient’s balance remains unpaid for thirty
(30) days or more, in addition to Soothing Dental’s right to run the credit card on file,
or other electronic payment method selected by Member or Patient, for the balance
to be paid in full, Soothing Dental reserves the right to pursue legal action to collect
any outstanding amounts, and Member/Patient will be responsible for any attorney’s
fees, collection fee, bank charges, or court costs that may be incurred to satisfy
their obligation.
16. Should a Patient or Member default on an agreed upon Discount Service or
payment plan, Soothing Dental reserves the right to not enroll the Patient or Member on
any and all Discount Service or payment plan thereon.
17. In the event that a Patient or Member, disputes a charge on their Preferred
Method of Payment for an amount due to Soothing Dental, there will be a 4%
Processing Fee that will be added to the original amount due at the time of collection.
18. Returned checks or Declined Credit cards: There is a fee, currently $35, for
any checks returned by the bank or for Declined Credit Cards. Before we accept
another payment by check, the $35 fee plus full payment for the check that did not clear
must be paid in cash, or by credit card.
19. Soothing Dental is subject to complex laws and regulations that are
constantly evolving and vary from state to state. Specific billing practices and service
availability may be amended periodically to comply with changes in the law or guidance
from Plans and regulatory authorities.
20. The remedies in the Financial Policy are cumulative.
21. Patient or Member agrees to pay a stop-cheque fee of $35 in the event of
need for issuance of a new cheque, if cheque is lost in the mail or Patient has not
provided the updated address to Soothing Dental within 15 days of their address
change. This amount would be deducted from the new cheque being issued.
22. In the event of prepayment for a procedure, if Patient changes their decision
in proceeding with the treatment as planned and accepted, Soothing Dental reserves
the right to charge 4% on the amount being refunded to Patient as payment processing
fee that needs to be paid to Credit Card processing vendors.
23. Soothing Dental will keep a preferred method of payment for Patients on
their account.
24. In the event that a Patient or Member wants to change the Payment Method
utilized for a payment after one has already been processed, Soothing Dental reserves
the right to charge 4% Processing Fee to the amount processed.
25. Any payments due, including but not limited to Service Agreement,
Monthly Payment arrangements, or any balance due will not be suspended or
waived due to Force Majeure events included but not limited to war, riots, famine,
acts of God (earthquake, hurricane and extreme weather), pandemic or epidemic,
etc.
G. Discount Offers/Plans offered by Dental Practice:
1. Dental Practice may offer Discount Offers/Plans to a Patient, who does not
have Dental Coverage otherwise.
2. Discount Offers shall provide discounts off of the Usual, Customary and
Reasonable fee schedule of the Dental Practice (“UCR” fee) for Dental Services
provided by the Dental Practice, which are subject to change from time to time,and in
the sole discretion of Dental Practice.
3. Discount Plans shall not apply to the cost of any services provided by any
third- party office or provider; those costs shall be paid separately as an out-of-pocket
expense by the Patient.
4. Any Discount Offer selected by the Member shall remain in effect for two (2)
years or until such other time as provided in the corresponding agreement (“Discount
Offer Period”) unless this Agreement is sooner terminated by either party, as provided
herein.
5. The cost of the Discount Offers shall be paid on a monthly basis on an
automatic basis and using a valid Credit Card. The cost of any Dental Service under
these Discount Offers shall be paid at the time of service or in some other manner
mutually agreed to by the Dental Practice and Patient.
6. After the 2-year or such other time as provided for the Discount Plan, payment
will be on a month-to-month basis thereon on an automatic basis unless the Member
asks for its termination.
7. Discount Offers can be upgraded to a higher Plan during the 2-year
commitment period; however, they can NOT be downgraded during that time.
8. Relocation of Patient prior to the 2-year term,or not using the benefits during
such term is not basis for early termination without penalty of the 2-year commitment
period. Should that be the case, Patient/Member is still liable for the entire 2-year
Service Fee or the equivalent UCR fee for services rendered.
H. Appointment Cancellation Policy :
1. Soothing Dental requires 48-business hour prior notice for any appointments
that are rescheduled or canceled for any and all reasons.
2. For every hour missed, an hourly fee ($75 currently), will be charged for
appointments canceled without prior notification, and Patient agrees to permit Soothing
Dental to charge this amount to their selected electronic payment method immediately.
I. Term, AUTO-RENEWAL, and Termination :
1. This Agreement shall commence on the earlier of the date of: (i) enrollment as
a Member or Patient, (ii) setting an appointment for Dental Services, or (ii) establishing
an account on the Soothing Dental Site.
2. This agreement, including the membership period, the discount offer/plans,
shall automatically renew on the same terms, unless Member/Patient or Soothing
Dental notifies the other party no less than 30 days prior to the expiration date or as
otherwise provided in this Agreement.
3. Either Patient or Soothing Dental may terminate this Agreement and Patient’s
right to use Soothing Dental at any time, with or without cause. Any outstanding balance
on Patient’s account shall be due in full at the time of termination.
4. After termination, Soothing Dental shall retain Patient’s Record in the
EHR for a period of time as required by law.
5. If this Agreement is terminated by the Member or Patient prior to the
conclusion of the Agreement term, then Member shall pay the total cost for any Dental
Services provided to the Patient at UCR, including outstanding fees and interest as set
forth on an invoice provided by Soothing Dental (“Cancellation Payment”).
6. Soothing Dental may elect to terminate this Agreement if a Patient or Member
fails to follow Dental Practice’s recommended treatment plan by providing thirty (30)
days prior written notice to the Patient or Member (mail or email).
7. Soothing Dental may elect to terminate this Agreement if a Patient or Member
commits any or all of the following actions (1) prohibited harassment, discrimination, or
retaliation towards a staff member, patient or individual, (2) committing an act of
violence, threats of violence, or brining a weapon to a practice premises, (3) reasonable
suspicion that the patient is under the influence while on the practice premises, (4) an
act of theft or embezzlement by patient, (5) lying or deceit committed by patient, or (5)
any other reason in which Dental Practice feels staff or patient health or safety is at risk.
Termination shall become effective on the date that Soothing Dental mail or email
written notice to the Patient or Member, using the address on file.
8. After Termination,
o If a balance remains on Patient’s account for fifteen (15) days
after termination, Soothing Dental reserves the right to run the electronic
payment method selected by Member or Patient.
o Any licenses granted to access the EHR shall terminate without
notice in the event Member or Patient (or any authorized person using your
account).
J. Limitation of Liability; Indemnity:
1. To the full extent permitted by law:
(a) In no event will Soothing Dental be liable for any indirect, incidental,
special, consequential or punitive damages arising out of or related to this
agreement, even if Soothing Dental has been advised of, knew of, or should
have known of the possibility of such damages; and,
(b) In any event, Soothing Dental’s total aggregate liability in connection
with this agreement, for all claims of any kind (including, but not limited to, any
claim related to the services performed by Soothing Dental hereunder, or
Patient’s use thereof), will not exceed the amount that Patient has paid to
Soothing Dental during the annual period immediately preceding the first event
giving rise to such liability.
2. To the extent permitted by law, Member/Patient agree to release,
indemnify and hold Soothing Dental, its shareholders, members, managers,
owners, advisors, officers, directors, affiliates, employees, and agents
harmless from all liabilities, claims, expenses arising from Member or
Patient’s acts or omissions, injury or personal damage that occurs during
Member or Patient’s use of the Soothing Dental Site including all of
Soothing Dental’s dental practice location, choice of payment method, or
receipt of notices or information at the contact address Member or Patient
has provided.
K. Disputes:
Member or Patient agrees that this Agreement is governed by the substantive
and procedural laws of the State of California, and the California Arbitration Act. Any
dispute arising out of or relating to this Agreement, including the determination of the
scope or applicability of this clause shall be settled by binding arbitration administered
by Judicial Arbitration and Mediation Services (JAMS) in accordance with its
Streamlined Arbitration Rules and Procedures. The arbitration shall be heard by a single
arbitrator, and shall be conducted in San Francisco, California. Each party shall bear
his, her, or its own costs relating to such arbitration, and the parties shall equally share
the arbitrator’s fees. Judgment on any award resulting from such arbitration may be
entered in any court having jurisdiction. If this arbitration provision is deemed invalid, the
parties agree that the court of proper and exclusive jurisdiction to resolve any action
arising out of this agreement shall be a state or federal court located in San Francisco,
California. Each party to this agreement hereby waives any right he/she or it may have
to participate in any class action or class arbitrations. The prevailing party shall be
entitled to collect its full attorney fees and costs.
O. Notice:
Soothing Dental will generally communicate with Member or Patient using the
email address or telephone number provided to Soothing Dental. Member/Patient may
contact Soothing Dental on all matters relating to Services provided by using the
following resources:
Soothing Dental: 450 Sutter St, #2500 San Francisco, CA 94108
For Customer Service inquiries: (415) 989-3953
L. General Provisions:
1. This Agreement, including Consent to Treatment, Terms and Conditions, and
Notice of Privacy Practices, shall constitute the entire Agreement between Patient and
Soothing Dental with respect to the subject matter hereof. If any provision of this
Agreement is, for any reason, deemed unenforceable or in violation of law, such
unenforceability or violation will not affect the remaining provisions of this Agreement,
which will continue in full force and effect and be binding upon the parties hereto.
2. Soothing Dental has the right to ask and store the Social Security number of
the Patient or Member as well as a form of Government Identification.
M. Binding Effect
The terms and provisions of this Agreement shall be binding and inure to the
benefit of the successors and assigns of the parties hereto.
N. Severability
In the event any provision herein is determined to be illegal or unenforceable,
such determination shall not affect the validity of enforcement of the remaining
provisions herein, all of which shall remain in full force and effect.
O. Descriptive Headings
The descriptive headings used and inserted into this Agreement are for
convenience only and shall not be deemed to affect the meaning or construction of any
provision herein.
P. Counterparts
This Agreement may be executed in one or more counterparts, each of which
shall be deemed an original, but all of which together shall constitute one and the
same instrument. This Agreement shall become effective upon the execution of a
counterpart hereof by each of the parties hereto.
Q. Entire Agreement
This Agreement and the Exhibits, if any, hereto constitute the entire agreement
Soothing Dental, and Member or Patient relating to the subject matter of this
Agreement. There are no other terms, obligations, covenants, representations, or
statements. No prior or subsequent agreements or understandings, either written or
oral, pertaining to the same shall be valid or of any force or effect, except in writing
and signed by the parties hereto.
R. Revisions
This Agreement may be revised or modified from time to time by Soothing
Dental. Revised agreements take effect upon execution by Member or Patient. Failure
to accept revised or modified Agreements shall cause Member’s Services or Discount
Offers Agreement to terminate within thirty (30) days of Patient or Member’s refusal to
execute the revised agreement.
Updated October 2024
Copyright ©2024 Soothing Dental
Dental Materials – Advantages & Disadvantages
PORCELAIN FUSED
TO METAL
This type of porcelain is a glasslike material that is “enameled”
on top of metal shells. It is toothcolored and is used for crowns
and fixed bridges
Advantages
❤ Good resistance to further
decay if the restoration fits well
❤ Very durable, due to metal
substructure
❤ The material does not cause
tooth sensitivity
❤ Resists leakage because it can
be shaped for a very accurate
fit
Disadvantages
• More tooth must be removed
(than for porcelain) for the
metal substructure
• Higher cost because it requires
at least two office visits and
laboratory services
GOLD ALLOY
Gold alloy is a gold-colored
mixture of gold, copper, and other
metals and is used mainly for
crowns and fixed bridges and
some partial denture frameworks
Advantages
❤ Good resistance to further
decay if the restoration fits well
❤ Excellent durability; does not
fracture under stress
❤ Does not corrode in the mouth
❤ Minimal amount of tooth needs
to be removed
❤ Wears well; does not cause
excessive wear to opposing
teeth
❤ Resists leakage because it can
be shaped for a very accurate
fit
Disadvantages
• Is not tooth colored; alloy is
yellow
• Conducts heat and cold; may
irritate sensitive teeth
• High cost; requires at least two
office visits and laboratory
services
DENTAL BOARD OF CALIFORNIA
1432 Howe Avenue • Sacramento, California 95825
www.dbc.ca.gov
Published by
CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
5/04
The Facts About Fillings
Reprinted in 2019
The Facts
About Fillings
DENTAL BOARD OF CALIFORNIA
1432 Howe Avenue • Sacramento, California 95825
www.dbc.ca.gov
2005 Evergreen Street, Suite 1550, Sacramento, CA 95815
2005 Evergreen Street, Suite 1550, Sacramento, CA 95815
Dental Materials Fact Sheet
What About the Safety of Filling Materials?
Patient health and the safety of dental treatments are the
primary goals of California’s dental professionals and the
Dental Board of California. The purpose of this fact sheet is to
provide you with information concerning the risks and benefits
of all the dental materials used in the restoration (filling) of
teeth.
The Dental Board of California is required by law* to make
this dental materials fact sheet available to every licensed
dentist in the state of California. Your dentist, in turn, must
provide this fact sheet to every new patient and all patients of
record only once before beginning any dental filling procedure.
As the patient or parent/guardian, you are strongly encouraged
to discuss with your dentist the facts presented concerning the
filling materials being considered for your particular treatment.
* Business and Professions Code 1648.10-1648.20
Allergic Reactions to Dental Materials
Components in dental fillings may have side effects or cause
allergic reactions, just like other materials we may come in
contact with in our daily lives. The risks of such reactions are
very low for all types of filling materials. Such reactions can be
caused by specific components of the filling materials such as
mercury, nickel, chromium, and/or beryllium alloys. Usually,
an allergy will reveal itself as a skin rash and is easily reversed
when the individual is not in contact with the material.
There are no documented cases of allergic reactions to composite resin, glass ionomer, resin ionomer, or porcelain. However,
there have been rare allergic responses reported with dental
amalgam, porcelain fused to metal, gold alloys, and nickel or
cobalt-chrome alloys.
If you suffer from allergies, discuss these potential problems
with your dentist before a filling material is chosen.
PORCELAIN
(CERAMIC)
Porcelain is a glass-like material
formed into fillings or crowns
using models of the prepared
teeth. The material is toothcolored and is used in inlays,
veneers, crowns and fixed
bridges.
Advantages
❤ Very little tooth needs to be
removed for use as a veneer;
more tooth needs to be removed for a crown because its
strength is related to its bulk
(size)
❤ Good resistance to further
decay if the restoration fits well
❤ Is resistant to surface wear but
can cause some wear on
opposing teeth
❤ Resists leakage because it can
be shaped for a very accurate
fit
❤ The material does not cause
tooth sensitivity
Disadvantages
• Material is brittle and can break
under biting forces
• May not be recommended for
molar teeth
• Higher cost because it requires
at least two office visits and
laboratory services
NICKEL OR COBALTCHROME ALLOYS
Nickel or cobalt-chrome alloys
are mixtures of nickel and
chromium. They are a dark silver
metal color and are used for
crowns and fixed bridges and
most partial denture frameworks.
Advantages
❤ Good resistance to further
decay if the restoration fits
well
❤ Excellent durability; does not
fracture under stress
❤ Does not corrode in the mouth
❤ Minimal amount of tooth needs
to be removed
❤ Resists leakage because it can
be shaped for a very accurate
fit
Disadvantages
• Is not tooth colored; alloy is a
dark silver metal color
• Conducts heat and cold; may
irritate sensitive teeth
• Can be abrasive to opposing
teeth
• High cost; requires at least two
office visits and laboratory
services
• Slightly higher wear to
opposing teeth
2 The Facts About Fillings 7
Dental Materials – Advantages & Disadvantages
GLASS IONOMER
CEMENT
Glass ionomer cement is a selfhardening mixture of glass and
organic acid. It is tooth-colored
and varies in translucency. Glass
ionomer is usually used for small
fillings, cementing metal and
porcelain/metal crowns, liners,
and temporary restorations.
Advantages
❤ Reasonably good esthetics
❤ May provide some help against
decay because it releases
fluoride
❤ Minimal amount of tooth needs
to be removed and it bonds
well to both the enamel and the
dentin beneath the enamel
❤ Material has low incidence of
producing tooth sensitivity
❤ Usually completed in one
dental visit
Disadvantages
• Cost is very similar to composite resin (which costs more
than amalgam)
• Limited use because it is not
recommended for biting
surfaces in permanent teeth
• As it ages, this material may
become rough and could
increase the accumulation of
plaque and chance of periodontal disease
• Does not wear well; tends to
crack over time and can be
dislodged
RESIN-IONOMER
CEMENT
Resin ionomer cement is a
mixture of glass and resin polymer
and organic acid that hardens with
exposure to a blue light used in
the dental office. It is tooth
colored but more translucent than
glass ionomer cement. It is most
often used for small fillings,
cementing metal and porcelain
metal crowns and liners.
Advantages
❤ Very good esthetics
❤ May provide some help against
decay because it releases
fluoride
❤ Minimal amount of tooth needs
to be removed and it bonds
well to both the enamel and the
dentin beneath the enamel
❤ Good for non-biting surfaces
❤ May be used for short-term
primary teeth restorations
❤ May hold up better than glass
ionomer but not as well as
composite
❤ Good resistance to leakage
❤ Material has low incidence of
producing tooth sensitivity
❤ Usually completed in one dental
visit
Disadvantages
• Cost is very similar to composite resin (which costs more than
amalgam)
• Limited use because it is not
recommended to restore the
biting surfaces of adults
• Wears faster than composite and
amalgam
Toxicity of Dental Materials
Dental Amalgam
Mercury in its elemental form is on the State of California’s
Proposition 65 list of chemicals known to the state to cause
reproductive toxicity. Mercury may harm the developing brain of
a child or fetus.
Dental amalgam is created by mixing elemental mercury (43-
54%) and an alloy powder (46-57%) composed mainly of silver,
tin, and copper. This has caused discussion about the risks of
mercury in dental amalgam. Such mercury is emitted in minute
amounts as vapor. Some concerns have been raised regarding
possible toxicity. Scientific research continues on the safety of
dental amalgam. According to the Centers for Disease Control
and Prevention, there is scant evidence that the health of the vast
majority of people with amalgam is compromised.
The Food and Drug Administration (FDA) and other public
health organizations have investigated the safety of amalgam
used in dental fillings. The conclusion: no valid scientific evidence has shown that amalgams cause harm to patients with
dental restorations, except in rare cases of allergy. The World
Health Organization reached a similar conclusion stating, “Amalgam restorations are safe and cost effective.”
A diversity of opinions exists regarding the safety of dental
amalgams. Questions have been raised about its safety in pregnant women, children, and diabetics. However, scientific evidence and research literature in peer-reviewed scientific journals
suggest that otherwise healthy women, children, and diabetics are
not at an increased risk from dental amalgams in their mouths.
The FDA places no restrictions on the use of dental amalgam.
Composite Resin
Some Composite Resins include Crystalline Silica, which is on
the State of California’s Proposition 65 list of chemicals known
to the state to cause cancer.
It is always a good idea to discuss any dental treatment
thoroughly with your dentist.
6 3
Dental Materials – Advantages & Disadvantages
DENTAL AMALGAM FILLINGS
Dental amalgam is a self-hardening mixture of silver-tin-copper alloy
powder and liquid mercury and is sometimes referred to as silver
fillings because of its color. It is often used as a filling material and
replacement for broken teeth.
Advantages
❤ Durable; long lasting
❤ Wears well; holds up well to
the forces of biting
❤ Relatively inexpensive
❤ Generally completed in one
visit
❤ Self-sealing; minimal-to-no
shrinkage and resists leakage
❤ Resistance to further decay is
high, but can be difficult to
find in early stages
❤ Frequency of repair and
replacement is low
Disadvantages
• Refer to “What About the
Safety of Filling Materials”
• Gray colored, not tooth colored
• May darken as it corrodes; may
stain teeth over time
• Requires removal of some
healthy tooth
• In larger amalgam fillings, the
remaining tooth may weaken
and fracture
• Because metal can conduct hot
and cold temperatures, there
may be a temporary sensitivity
to hot and cold.
• Contact with other metals may
cause occasional, minute
electrical flow
COMPOSITE RESIN FILLINGS
Composite fillings are a mixture of powdered glass and plastic resin,
sometimes referred to as white, plastic, or tooth-colored fillings. It is
used for fillings, inlays, veneers, partial and complete crowns, or to
repair portions of broken teeth.
Advantages
❤ Strong and durable
❤ Tooth colored
❤ Single visit for fillings
❤ Resists breaking
❤ Maximum amount of tooth
preserved
❤ Small risk of leakage if bonded
only to enamel
❤ Does not corrode
❤ Generally holds up well to the
forces of biting depending on
product used
❤ Resistance to further decay is
moderate and easy to find
❤ Frequency of repair or replacement is low to moderate
Disadvantages
• Refer to “What About the
Safety of Filling Materials”
• Moderate occurrence of tooth
sensitivity; sensitive to
dentist’s method of application
• Costs more than dental
amalgam
• Material shrinks when
hardened and could lead to
further decay and/or temperature sensitivity
• Requires more than one visit
for inlays, veneers, and
crowns
• May wear faster than dental
enamel
• May leak over time when
bonded beneath the layer of
enamel The durability of any dental restoration is influenced not only by the material it is made
from but also by the dentist’s technique when
placing the restoration. Other factors include the
supporting materials used in the procedure and
the patient’s cooperation during the procedure.
The length of time a restoration will last is
dependent upon your dental hygiene, home care,
and diet and chewing habits.
4 The Facts About Fillings 5