WELCOME TO DR. CHERYL SCOTT’S OFFICE: We primarily treat TMJ-related problems, but we use a variety of orthotic and orthodontic appliances that can help resolve other craniofacial issues related to the chewing system. Non-surgical approaches can address mild to moderate problems often at the same time. Symptoms of jaw, head, and neck pain, pain when chewing, upper airway restrictions resulting in sleep problems, problems with hearing, and vision; and chronic inflammation limit the quality of life. _________________________________________________________________________________________________________ INSURANCE coverage for TMJ care is limited to oral surgeons. Non-surgical care is not yet organized for negotiation with insurers. We provide a diagnostic report and payment receipts that, in some cases, can be mailed to your insurer or used for tax receipts. Medicare will not cover or reimburse you for our care. We cannot submit claims to medical insurers. __________________ __________________________________________________________________________________________________________ The FIRST APPOINTMENT is a 45-minute face-to-face consultation with the doctor. Before this visit, Dr. Scott reviews the online patient questionnaire to become oriented to your issues. The consultation includes a brief exam. The cost is $150. ________________________________________________________________________________________________________ The SECOND APPOINTMENT is a two-hour clinical exam that includes CT imaging of the TM joints, custom impressions, documentation, testing, and screening. The cost is $880. _____________________________________________________ ________________________________________________________________________________________________________ The THIRD APPOINTMENT is to start phase one non-surgical treatment for the TM joints for most patients. Treatment is wearing a custom-made Pivot-Splint, Crozat, Lightwire, or other intraoral orthotic or orthodontic appliance. All of the devices are designed to be adjusted over time so treatment requires appointments for 6 to 12 months. Most appointments are 20 minutes. ________________________________________________________________________________________________________ TREATMENT COSTS are packaged into one price, and there are usually no additional costs when treatment takes longer than estimated. The usual cost for the phase-one package is $5850 which includes all appointments, materials, and devices as needed. ________________________________________________________________________________________________________ TERMS of PAYMENT: The cost of treatment is due on the first day of treatment. Although pain may be improved quickly in some cases, treatment will take from 6 to 12 months when healthy adaptations have become established and stable. We make this payment policy fair by reducing the cost by at least 10% for care. We offer a 2% discount to pay in full by check. We accept most credit cards and CareCredit.com: Please apply online with CareCredit.com. We offer the 6-month plan at zero interest and fees; After we charge the cost of treatment, we suggest calling CareCredit to set up auto-withdrawal to avoid penalities. ________________________________________________________________________________________________________ CONCURRENT CARE may also be needed and you might be referred to other providers which would be additional costs. ________________________________________________________________________________________________________ PHASE TWO is assessed as you complete phase one. We include an assessment for phase two in the cost of phase one. Phase two can address underlying issues that prevent you from having a healthy bite and the need for a sleeping appliance. _________________________________________________________________________________________________________ PATIENT QUESTIONNAIRE: This form follows federal guidelines for privacy and security, and your information is for internal use only. Please take the time and provide details and anything possibly related to the issues. If a doctor or dentist referred you, please let us know. Dr. Scott will review your questionnaire before we schedule your first appointment. She cannot provide a medical opinion or make recommendations until after the first appointment. If you have general questions, please feel free to type them into the text box at the bottom of page 11. There is no charge or obligation for Dr. Scott to review the questionnaire. _________________________________________________________________________________________________________ APPROVE CONSENT: Click the link below to indicate you have read and agree to these disclosures and terms of care. Clicking the "Approve Consent" button will start the questionnaire. Keep entering information until you click, "Send Form." You are welcome to copies of your medical records at any time. We have to keep the original records. We will confirm with you before we request or send your records. We provide medical care that falls under the Health Department's laws and policies. Steve Roberts for Dr. Scott