FINANCIAL AGREEMENT

Thank you for choosing us as your healthcare provider. We provide comprehensive dental care for adults and children. With highly skilled dentists, a well trained and caring staff and today’s most advanced technology, we are dedicated to being the best dental office you will ever experience. Our office is committed to excellence in everything we do. We will make your dental visit as comfortable as productive as possible as we show you how ideal dentistry can ensure YOUR health. We have several financial options available for you convenience. We have found that our patients appreciate knowing exactly what their financial responsibilities are. Therefore, we inform our patients about our financial policy before we begin treatment.

IF YOU HAVE DENTAL INSURANCE

Please take the time to review your dental benefits. Understand that the dental insurance is a contract between the patient and the insurance carrier and not between the carrier and the dentist. Patients are responsible for any charges for procedures not covered by insurance. Note that Deductibles, co-insurance, and charges not covered by insurance are due at the time the service is rendered. Unless a pre-approved determination of benefits has been received, all co-insurance are estimated based on your benefit plan. Therefore, there may be adjustments made to your bill after the actual payment is received.

MISSED APPOINTMENTS

Once an appointment has been made, please remember that this time has been reserved for you. No charge will be made for rescheduling an appointment provided that a 24 hour notice has been given. Otherwise, a charge of $75.00 per hour missed will be incurred and payable before your next appointment.

PAYMENT OPTIONS

We provide several financial options. We accept cash, check and credit cards (Visa, Mastercard, American Express and Discover). By moving forward with treatment, you have indicated that you will comply with this policy. There is a $25.00 charge on all returned checks.

Thank you for trusting us with your dental care. It is our desire to enable everyone of our patients to achieve an optimum level of health, durability and aesthetics a beautiful smile for a lifetime.

I have read, understand and agree to the provisions of this financial policy.
Patient Signature (or Parent/Guardian Signature if Minor)
Date