We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please ask us - we will be happy to help.


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PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

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MEDICAL UPDATES (for future use)


We believe that each patient deserves to know what their current level of dental health is, how they got there, and what treatment options are available to help them reach the level of health that they deserve. This begins with a careful diagnosis and personalized treatment plan. We will perform a comprehensive oral examination of your teeth, gums, jaw joints, bite and soft tissues. We will also take the appropriate X-rays, and when beneficial we may take additional diagnostic records such as photographs or casts of your teeth to further evaluate areas of concern. Once all your records have been completed they will be carefully evaluated to determine your current level of dental health and how you got there. We will review our findings with you and discuss your treatment options. A personalized treatment plan will then be developed to help you achieve the goals we set together

HEALTH LEVEL I - Emergency Care

HEALTH LEVEL II - Maintenance Care

HEALTH LEVEL III - Comprehensive Care

HEALTH LEVEL IV - Comprehensive & Cosmetic Care


We value your time, please value ours. Because we recognize the value of your time, you can expect us to see you at the appointed time and to keep your time spent in our office as short as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Also, please make every effort not to change your schedule appointment. If you find you must change an appointment, please provide us at least 48 hour advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. An hourly charge may be applied for broken or missed appointments without adequate advanced notifications. Thank you for your cooperation in this matter.


  • Unless another financial option is PRE-ARRANGED, payment in full is due the day of treatment.
  • For procedures longer than 1 HOUR, 1/3 down is expected to reserve the appointment time.
Payment Options
  1. For your convenience we accept Cash, Check, Visa, MC, American Express and Discover.
  2. We also offer short and long-term financing through Care Credit, Lending Club, and Proceed Financing
    (12 months interest free financing may apply)
For patients with Dental Insurance
  1. Patient chooses to pay in full for all treatment and will accept the offer from Mandeville Center for Dental Excellence to electronically file patients claim with the insurance carrier for direct reimbursement to the patient.

  2. Patient agrees to pay a deposit for all treatment and will accept the offer from Mandeville Center for Dental Excellence to electronically file and accept payments from insurance carrier. Patient understands to receive this benefit, patient's credit card information will be needed to guarantee the account. Patient understands that as soon as the insurance carrier issues a payment, or 90 days, the unpaid portion of the claim will be charged to patient's credit card without penalty or interest. Patient understands that if for some reason the credit card is not available for covering the treatment balance, patient is responsible for payment with interest and penalties.

  3. We are happy to help you file your insurance claims. Your insurance is a contract between you and your insurance company that we have no control over. Dr. Schof is not in contract with any insurance company. You are responsible for any balances that your insurance does not cover.


General Consent to Treatment
  • I agree and consent to a dental examination by Dr. Schof. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed.
Release of Information
  • I authorize Dr. Schof to release any information regarding my dental/medical history,
    diagnosis or treatment to third party payors and/or other health professionals.
Assignment of Insurance Benefits
  • I authorize and request my insurance company to pay my benefits directly to Dr. Schof.
Photography Release
  • I authorize Dr. Schof to take photographs of me to help me better understand my current dental condition and possible treatment options. I also authorize him to show these photographs to other patients to better explain their treatment options (as you may be shown photographs for the same reason)
  • I understand and will comply with office Appointment Policy.
  • I understand and will comply with the office Financial Policy.
  • I understand and agree to the General Consent to Treatment.
  • I authorize the Release of Information.
  • I authorize Photographs to be taken of me and shown to other patients.
  • I have received a copy of the office's Notice of Privacy Practices.



Charles A. Schof, D.D.S.


Dental Disease


Optimum Dental

If we are to make your mouth healthy and keep it that way, we must accomplish two things:
  1. We must leave no place in you mouth that is not completely cleanable
  2. We must reduce all the stresses in your mouth to a point where they are not destructive.