Photo Release
Carolina Avenue Dental Care
214 Carolina Avenue
Moncks Corner, SC 29461
I, _____________________________________,
Hereby authorize Dr. Gloria Pipkin & Dr. E. Stephen Fragale or their assistants to take photographs,
slides, and/or videos of my face, jaws, mouth, and teeth.
I understand that the photographs, slides, and/or videos will be used as a record of my care, and may
be used for educational purposes in study club meetings, lectures, seminars, demonstrations, and
professional publications (journals, magazines).
I further understand that if the photographs, slides, and/or videos are used in any publication or as a
part of a demonstration, my name or other identifying information will be kept confidential.
I do not expect compensation, financial or otherwise, for the use of these photographs.
Signature: (Patient / Responsible Party) ______________________Date ____________
Carolina Avenue Dental Care
Gloria B. Pipkin DMD & E. Stephen Fragale DDS
Office Policies
In order for us to provide you with outstanding customer service and care, the following policies are in place at
Carolina Avenue Dental Care:
Payment is due when services are rendered: We accept cash, checks, and all major credit/debit cards.
Additional financing is available pending approval through care credit. In- office financing is not available._____
Insurance: We accept payment from all dental plans; however we do expect the estimated co-payment portion
of your bill to be paid at the time of service. The balance is your responsibility whether your dental plan pays or
not. Your dental plan is a contract between you and your insurance company. We are not a party to that
contract. It is your responsibility to check if we are an in network provider for your insurance plan.
Please be aware that some and perhaps all of the services provided may be non-covered services and are not
considered reasonable and customary under your dental plan. Our practice is committed to providing the best
treatment for our patients and we charge what is usual and customary for our area in accordance with the fees
set by the South Carolina Dental Association. You are responsible for payment regardless of any insurance
company’s arbitrary determination of usual and customary rates. Please be advised that if your treatment is
not covered under your specific dental plan, full payment is due at the time of service. ______
Crowns, bridges, dentures, etc.: ½ of the charge is to be paid when casting and prep is done, and balance is
due at the time of delivery. For Invisalign services: $500.00 is due at the initial visit. $1000.000 is due on the
day impressions are taken, and the remaining balance will be discussed at that time. _______
Delinquent account procedure:
30 days past due: A statement will be sent. It will reflect the current balance due.
60 days past due: A statement will be sent and you will be given 30 days to pay full balance.
90 days past due: A Certified Letter will be sent along with your statement. You will be given 10 days to pay
your full balance. After the 10 day period collections proceedings will be initiated.
Once your delinquent account has been sent to collections we CANNOT accept partial payments on
your account. Payment must be made in full before any other appointments can be scheduled._______
Appointments: Appointments are made by you in accordance with your schedule. We understand that “life”
happens but as a courtesy to us and our other patients please give us at least 24 hours notice if you must
reschedule your appointment , so your previously reserved time can be given to another patient in need of
dental treatment. If you “Cancel” with less than 24 hour notice or “no-show” for your appointment you
will be charged a $25 broken appointment fee. ______
Consent for treatment/signature on file:
My signature below also acts as my permission to have Dr. Pipkin or Dr. Stephen Fragale perform the
procedures or treatments that they have reviewed with me. I also authorize them or their assignee to bill my
insurance company for the procedure or treatment on my behalf. This acts as my signature on file for her or
her assignee to act on my behalf for any purposes she deems necessary in relationship to my care._______
I have read the above policy and agree to its content.
Responsible Party:_________________________________ Date:_________________________