Consent & Agreements
I agree to notify this office of any change in the patient's medical history and/or medication.
I give my consent to needed dental services.
Missed Appointment Agreement
We make every effort to value your time and we schedule your appointment time just for you. We require a minimum of 48 hours notice to change my appointment for any reason.
We will not charge for your first missed appointment however you may be required to make a deposit when scheduling the next appointment. A minimum of $25 will be charged for your 2nd missed appointment. This charge can be as high as half of your portion after insurance. The payment will be applied toward lost production time.
I acknowledge an appointment is a reservation. I understand that charges will be incurred for missed appointments as stated above.
I authorize payment of insurance benefits directly to Chattahoochee Valley Dental.
I authorize the release of all necessary information to my insurance carrier.
Office Payment Policy
I understand that the responsibility for payment for dental serviced provided in this office for me or my dependents is mine. I agree to pay all unpaid balances. Any account over 30 days past due will be assessed a monthly billing charge equal to 1 ½ % of the unpaid balance (18% annually).
I understand that payment is expected at the time of service for all treatment unless other arrangments have been made prior to the appoint. This includes any amounts not expected to be covered by insurance.
I understand that you will file DENTAL insurance claims as a courtesy to me. I understand that the amount collected as a co-pay is an ESTIMATE. I understand that I am responsible for any balance due after my insurance has paid including any all remaining balance on my account due to policy exclusions or limitations.
I accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees (33.33%), attorney fees and/or court costs, if such be necessary.
I agree, in order for Chattahoochee Valley Dental to service my account or to collect monies I may owe, Chattahoochee Valley Dental and/or their agents may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in charges to me by my carrier. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.