FINANCIAL & DENTAL APPOINTMENT POLICIESThe relationships we build with our patients is very important to us. For this reason, we believe it’s necessary to establish a clear understanding about the financial responsibilities of that relationship.

Dentistry is an excellent investment in your overall health and for this reason, we provide the following options for payment:

Payment for dental services may be due upon scheduling and at a minimum, due when a service is provided. If you have dental insurance, your patient portion may be due upon scheduling, or at a minimum, due at the time service is provided.

For those with dental insurance:

Your dental appointments have been reserved exclusively for you. For this reason, if you need to make a change to your appointment date or time, we must receive a 2 working day notice. For longer appointments, we may request a 1 week notice. If you miss or cancel your appointment more than twice, we may ask you to prepay for your appointments(s) to reschedule or ask that you to seek dental care elsewhere. Please note that calls left on our voicemail when the office is closed (nights, holidays & weekends) is not considered as a working day notice. We will ask you to confirm your appointments in advance with courtesy reminders we will send you through email, text and or phone. Let’s work together to minimize last minute appointment changes, or worse, a last minute cancellation by honoring your commitment to all appointments you schedule.

I have read, understand and agree to all of the above.

We accept many dental insurance plans in this office and are happy to provide a benefits-check on your behalf. However, it is ultimately your responsibility to know all the details of your dental plan, including participating, non-participating, any limitations, exclusions, etc.

It is the patient’s responsibility to provide accurate dental insurance plan information prior to any dental treatment service. We cannot be held responsible for the outcome of any misinformation provided.

We are happy to submit claims to your dental insurance company on your behalf

We are happy to accept assignment of payment from your dental insurance company if they are willing to send payment to our office. For those dental plans that will not send payment to the dentist directly, we will collect your payment in full and submit a claim to your insurance plan on your behalf for any potential reimbursement to you.

You will receive a billing statement from our office should a balance exist after insurance payment(s) have been received. We are committed to providing our patients with the best estimates possible. We do this with as much information we are provided with by your insurance plan. Please understand that we cannot guarantee the estimate to be anything more than an estimate.

CashCheckMoney orderCredit Cards (VISA, MC, Amex and Discover)Monthly payment plans through Care Credit

PATIENT NAME (PLEASE PRINT)

PATIENT’S SIGNATURE DATE:

YOUR DENTAL APPOINTMENTS