Terms of Service

This page contains our Policies & Procedures, Consent for Treatment, our No Show / Late Cancellation Policy, and our HIPPA Notice of Privacy.  It was revised on 10/10/2016.


Our doctors and staff are committed to providing you with the best possible care. You can help us make your child’s first dental visit enjoyable and positive. Your child should be informed of the visit and told that our doctors and staff will explain everything and answer any questions. If you approach the visit in a casual manner the chances are much better that your child will do the same. It is best if you refrain from using words around your child that might cause unnecessary fear, such as needle, shot, pull, drill or hurt. We make a practice of using words that convey the same message, but are pleasant and non-frightening to the child. We believe in always being honest with your child. We would prefer that if you do not feel confident that you can honestly answer your child’s dental questions without provoking anxiety, you defer to us.

Children Under the Age of 3 – If your child is under the age of 3, we invite you to accompany your child to the treatment area during their dental visits. We frequently need assistance from parents with most children in this age group. We ask that whenever parents accompany children into the treatment area all other siblings not receiving dental treatment remain in the lobby with another adult.

Children Age 4 & Older – We have found that most children 4 years old and older have the best dental experiences when they go back to the open bay area on their own. When our amazing staff guides your children through their dental visit, communication and cooperation are ideal. All of our staff are gifted communicators with children and have undergone extensive training in verbal and nonverbal communication. It is easy for a nervous child to pick up on even slight anxiety in their parents. Going back without mom or dad is something that our kids grow to take pride in because they feel like they are being a “big boy” or “big girl.” Please encourage your school aged children to be ready to go back and see us while you wait for them in our lobby area. Please understand that if your child should become upset or anxious we will not hesitate to come and get you. Under those circumstances, we ask that whenever parents accompany children into the treatment area all other siblings not receiving dental treatment remain in the waiting area with another adult.

If you have dental or medical insurance, we are happy to help you receive your maximum allowable benefits. It is impossible for our office to know how much each company pays for each procedure and what they do not cover. Therefore, it is important for you to familiarize yourself with your insurance coverage. The fact that your insurance company does not cover a certain dental procedure does not mean that the procedure is not important for your child. Generally, a way in which your employer seeks to minimize the cost of insurance is by eliminating coverage of certain dental procedures, even though they are necessary in providing the best dental care for your child.

As dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we are happy to extend to our patients, all charges are your responsibility from the date the services are rendered. Payment of services is due at the time services are rendered, unless you are covered by dental insurance, at which time, you will be expected to pay your estimated portion. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. We realize that temporary financial problems affect timely payment on your account. Should such problems arise, please contact us promptly for assistance in the management of your account.

I have read and understand the above information. Furthermore, I understand that certain dental procedures may not be covered by my insurance. I agree to pay for any expenses not covered by my insurance. I understand that should there be a procedure that I do not wish to be performed on my child, that I must notify the office prior to my child’s visit. Should it be necessary to take action to collect any amount owing under this agreement, I/we agree to assume the cost incurred to collect including, but not limited to, collection agency fees, court costs, and interest accruing thereon at the rate of 1 ½ % per month.


Parents:  Prevailing medical/dental practice law requires that we ask you to read the following and sign at the bottom of the New Patient Forms page under the section entitled Terms of Service.  We apologize in advance for the impersonal nature of these statements.

By signing the Terms of Service section on the New Patient Forms, you agree to the following:

  • I am the parent or guardian of said patient and have legal authority to give consent for medical/dental treatment for him/her.
  • I give my consent to Dr. Clay P. Goins and other personnel as he may designate to render dental and/or any emergency medical procedures deemed necessary or advisable.
  • I give my consent to use of local anesthetics, nitrous oxide (laughing gas), and other medicines or materials as necessary.
  • The aspects of dental treatment have been previously explained to me to my satisfaction:  the procedures, the benefits and disadvantages of treatment, any alternatives, possible side effects and complications, as well as the prognosis if no treatment is provided.
  • I understand that in the course of treatment my child may become uncooperative and it may not be safe to complete treatment.  I also understand that I will be informed during and after treatment if more extensive behavior management such as sedation or general anesthesia is needed to complete treatment.
  • I understand that, although good results are expected, the possibility and nature of complications cannot always be accurately anticipated.  Therefore, there is no guarantee expressed or implied either to the result of treatment or as to the cure.
  • I have been given an opportunity to ask any questions I might have.
  • This consent will be enforced indefinitely until rescinded by me.
  • I have read and understand this consent policy.


This policy has been established to help us serve you better.

It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-shows and late-cancellations cause problems that go beyond a financial impact on our pratice. When an appointment is made, it takes an available time slot away from another patient. No-shows and late-cancellations delay the delivery of dental care to other patients, some of whom are in pain.

A “no show” is missing a scheduled appointment. A “late cancellation” is canceling an appointment without calling us to cancel within 24 hours of an office appointment or 72 hours in advance of a procedure.

We understand that situations such as medical emergencies occasionally arise. These situations will be considered on a case by case basis.



Please understand that insurance companies consider this charge to be entirely the patient’s responsibility. To cancel or reschedule an appointment please call Children’s Dentistry of Chattanooga at 423-954-9511. This policy is in effect to ensure that all of our patients have the opportunity to be seen in a timely manner.

By signing the Terms of Service on our New Patient Forms, you understand that, where appropriate, credit bureau reports may be obtained. To the best of my knowledge all the above information is correct.

HIPPA Notice of Privacy

You may view, download, and print a copy of our HIPPA Notice of Privacy by clicking the links below.

Page 1 – HIPPA Notice Of Privacy

Page 2 – HIPPA Notice Of Privacy