How to Become a Dental Clinic Patient
The Milestone Dental Clinic is not currently accepting new patients. We apologize for any inconvenience.
Checklist for new patient packets: (We must receive ALL forms to process them into our system)
- Patient History
- Patient Profile (2 pages)
- Consent for routine dental care
- Medical Immobilization Consent
- Acknowledgement of privacy practices
- Copy of Patient's physical
- Insurance information (IPA Card, Dental Insurance Card, Self-Pay information)
Click the button below to download the new patient packet.
All necessary forms must be completed before patients can be entered into the system or scheduled. We will not enter into our system and/or schedule any appointments until we receive all paperwork. No exceptions will be made.
DO NOT fax patient packets back to our clinic. Please mail back ALL completed originals to our office at 275 N. Phelps Ave., Rockford, IL 61108.
Policies regarding appointments
Fail / No Show Policy
The following policy is the FA/NS policy, which will be strictly enforced by the Milestone Dental Clinic. No exceptions will be made to this policy.
- There are many individuals waiting a long time for appointments
- Empty chair time is very costly to the program
- We expect responsibility and compliance from all of our patients
- Many dental procedures are time sensitive
Failed Appointment –you must call the clinic to cancel an existing appointment at least than 24 business hours notice before the appointment, or it will be considered a failed appointment unless you have a medical excuse. This means Monday appointments must be cancelled on Thursday.
No Show – failure to call or show up for a scheduled appointment. Arriving more than 10 minutes late without a valid and approved reason will be considered a no show.
The computer will track all missed appointments. Any patient with 2 missed appointments due to FA/NS will immediately become ineligible for the dental program. An individual may request reinstatement after 1 year by contacting the Program Administrator for instructions. A patient may be reinstated only once.
As a courtesy to our patients Milestone Dental Clinic makes an effort to confirm appointments the day before. However, it is not our responsibility to remind you of an upcoming appointment. If we attempt to reach you and find your phone number is no longer in service we will give your appointment to another patient. If you arrive for your appointment we will see you it our schedule permits.
If you reschedule an appointment after failing it will be your responsibility to call the clinic at least 24 hours before the appointment to let us know you intend to keep the appointment. If you do not call we will give your appointment to another patient.
Policy on Personnel in Treatment Areas
It is the policy of Milestone Dental Clinic that patients and dental clinic staff members ONLY are allowed in the treatment areas during treatment. There will be no exceptions to this policy. The rationale for this policy is that in order to most efficiently, effectively and safely treat our patients a minimum number of trained dental staff members only need to be present. Additional people in the treatment area adds to confusion, inhibits communication between the doctor and patient, creates possible safety issues (OSHA) and does not allow for the confidentiality of other patients in the clinic (HIPPA). Staff members and family members may be present to seat the patient and then will be asked to leave the treatment area when we are ready to begin treatment. If your assistance is needed at any time during treatment, a dental staff member will come to the reception area and get you. The dentist will speak to you before and or after the appointment, if necessary. If you have specific questions for the dentist please let a staff member know. If you choose not to adhere to this policy we will request that you seek dental care elsewhere. If you would like to discuss this policy further please contact the Clinic Administrator. We appreciate your cooperation with this policy.