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We value your time so you can expect us to see you at the appointed 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 as we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 24-hours 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. If you are more than 10 minutes late for your appointment, you may be asked reschedule. We value your time, so we ask that you please value ours as well.

Unless another financial option is PRE-ARRANGED, payment is due the day of treatment, or on pre-op visits for sedation appointments. Should a patient have dental insurance with assignment to Dr. Cansler, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Payment Options: For your convenience we accept cash, check, Visa, MasterCard, and Discover. We do not currently accept American Express, CareCredit, or LendingClub. For Patients with Dental Insurance: Dental insurance plans often pay less than the actual fee for service, therefore the patient or guarantor is the responsible party for all the dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be estimated and explained to you during the treatment discussion appointment. MEDICARE: Dr. Cansler does not participate with ANY Medicare plans and is considered "Opted Out". Medicare does not pay for any covered items or services you get from an opted out doctor or other provider, except in the case of an emergency or urgent need. Payment will be due at the time of service. We are happy to provide an itemized receipt to you if you choose to attempt to seek reimbursment from Medicare directly. We will allow a maximum of 90-days for your insurance company to clear account balances. Any unpaid portions will be due in full by you after this period. Fees: Returned checks are subject to a $30 account fee or 5% of check amount over $600.

General Consent to Treatment: I agree and consent to a dental examination by Dr. Cansler. I understand that additional diagnostic procedures and dental treatment 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 treatment performed. Release of Information: I authorize Dr. Cansler to release an 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. Cansler. Photography Release: I authorize Dr. Cansler to take photographs of me to help me better understand my current dental condition and possible treatment options. I understand and will comply with Appointment Policy. I understand and comply with the office Financial Policy. I understand and agree to the General Consent for Treatment.

I hereby acknowledge that I have reviewed Cansler Dental’s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice.